Cough with predominant fever and tachypnoea

PNEUMONIA

J18.9

DESCRIPTION

Infection of the lung parenchyma characterized by inflammation and consolidation of lung tissue. Management depends on the clinical assessment and classification of severity.

Empiric antibiotics are indicated in all cases of pneumonia, as delay in treatment is associated with poor outcome. Antibiotic choice is based on an assessment of severity and likely aetiology.

Common bacterial causes of pneumonia include:
Neonates:

  • Group B beta-haemolytic Streptococci.
  • Klebsiella spp.
  • E. coli.
  • Chlamydia.
  • S. aureus.

Children:

  • S. pneumoniae.
  • H. influenzae.
  • S. aureus.
  • M. catarrhalis.
  • M. pneumoniae.

Common viral causes in infancy and early childhood include:

  • influenza virus,
  • para-influenza virus,
  • measles virus,
  • respiratory syncytial virus,
  • cytomegalovirus,
  • adenovirus.

Measles is recognized by its other systemic manifestations. Staphylococcal pneumonia should be suspected if there is empyema, pulmonary cavitation or pneumatocoele formation or the presence of extrapulmonary pyogenic infections. Other than these two instances it is not usually possible to clinically determine the underlying pathogen.

Complications of pneumonia include:

  • respiratory failure,
  • pleural effusion,
  • empyema,
  • pneumothorax,
  • pleuritis,
  • bronchiectasis.

DIAGNOSTIC CRITERIA

  • Tachypnoea: age dependent:
Age Respiratory rate
< 60 days > 60/minute
2-12 months > 50/minute
1-5 years > 40/minute

Pneumonia (non-severe)

  • Cough and fast breathing (tachypnoea).

Severe pneumonia
Above plus one of the following:

  • lower chest wall in-drawing;
  • nasal flaring;
  • grunting.

Very severe pneumonia
Above plus at least one of the following:

  • central cyanosis, oxygen saturation < 90% in room air;
  • inability to feed;
  • convulsions, lethargy or decreased level of consciousness;
  • severe respiratory distress (e.g. very severe chest wall in-drawing);
  • < 60 days old.

Note:
All infants aged up to 60 days with pneumonia must be considered as having very severe disease.

Investigations

  • Perform a chest X-ray when there is failure to respond to therapy, in children with severe pneumonia in whom complications or tuberculosis are suspected, and in children with very severe pneumonia. Perform a lateral and AP or PA view if possible. A chest X-ray is not essential in all cases with severe pneumonia and is unnecessary in cases with non-severe pneumonia.
  • TB work up if tuberculosis suspected (e.g. TB contact) see Tuberculosis, Pulmonary .
  • In children with very severe pneumonia perform blood culture, preferably before initiating antibiotics.

GENERAL AND SUPPORTIVE MEASURES

  • Bed rest.
  • Clear nasal and oral passages of thick secretions.
  • Monitor:
    • respiratory rate,
    • heart rate,
    • SaO₂ ,
    • temperature,
    • hydration,
    • blood pressure,
    • hypercapnia and/or hypoxia are indications for ventilatory support.
  • Maintain nutrition: Continue breast and oral feeds.
    • Consider small frequent feeds by oro/nasogastric tube or IV fluids if respiratory rate > 60/minutes or enteral feeds are not tolerated.

MEDICINE TREATMENT

  • Oxygen, humidified, by nasal prongs is preferred.
    • Continue oxygen until respiratory distress and hypoxia resolves (a saturation of ≥ 92% off oxygen).

To relieve discomfort:

  • Paracetamol, oral/NGT, 15 mg/kg, 6 hourly as required.

If significant degree of wheezing is present:

  • Salbutamol, inhalation, 100–200 mcg, as required using a metered-dose inhaler with a spacer device or a nebulizer until symptoms are relieved.

Empiric antibiotic therapy

Choice of antibiotic depends on the severity of the condition, the age of the child and the presence of co-morbidity.
Reconsider choice of antibiotic when the results of cultures become available or the child does not improve.

Pneumonia (non-severe):

  • Amoxicillin, oral, 45 mg/kg/dose, 12 hourly for 5 days.

Severe pneumonia:

  • Amoxicillin, oral, 45 mg/kg/dose, 12 hourly for 5 days.

If child is unable to swallow or is vomiting:

  • Ampicilllin, IV, 25 mg/kg/dose, 6 hourly (change to oral as soon as able).

Very severe pneumonia
Assume child is HIV infected until proven otherwise.
See Human Immunodeficiency Virus Infections .

  • Ampicillin, IV, 50 mg/kg/dose 6 hourly.

PLUS

  • Gentamicin, IV, 6 mg/kg as a single daily dose for 5–10 days.

Switch to oral as soon as there is a response:

  • Amoxicillin/clavulanate, oral, 45 mg/kg/dose of amoxicillin component 12 hourly to complete 10 days total.

Measles Pneumonia
Treat as severe pneumonia, and see Measles.

MODIFICATION OF ANTIMICROBIAL THERAPY

If there is a poor response to first line empiric therapy and in the absence of positive cultures consider the possibility of infection with Staph aureus, penicillin resistant pneumococcus or mycoplasma. Think of pertussis and evaluate for tuberculosis. If nosocomial pneumonia suspected, refer to Nosocomial Pneumonia . Re-evaluate for possible co-morbidity (foreign body, immunodeficiency, heart disease).
If staphylococcal pneumonia is a consideration at presentation immediately start treatment with intravenous cloxacillin.
If mycoplasma is considered do either a bedside test for cold agglutinins or send blood for mycoplasma IgM and IgG levels. Both tests lack sensitivity.

Change to:

  • Ceftriaxone, IV, 80mg/kg/dose daily for 10 days.

PLUS

  • Cloxacillin, IV, 50 mg/kg/dose every 6 hours.

If there is evidence of good clinical response, change to:

  • Flucloxacillin, oral, 12.5–25 mg/kg/dose 6 hourly to complete at least 21 days of treatment.

OR (if flucloxacillin is unavailable)

  • Cephalexin, oral, 6.25–12.5 mg/kg/dose 6 hourly.

MRSA pneumonia:

  • Vancomycin, IV, 15 mg/kg/dose 6 hourly infused over 1 hour for 14 days.

Mycoplasma pneumonia:
Mild disease

  • Macrolide, e.g.:
    • Azithromycin, PO, 10 mg/kg/dose daily for 1 dose then 5 mg/kg/dose daily for 4 days.

Severe atypical pneumonia

  • Macrolide, e.g.:
    • Azithromycin, IV, 10 mg/kg/dose daily for 2 days.

THEN

  • Azithromycin, oral, 5 mg/kg/dose daily for 3 days.

SURGICAL TREATMENT

  • To relieve a tension pneumothorax, do needle aspiration followed by intercostal drain placement.
  • Small or asymptomatic pneumothoraces in infants and children (excluding neonates) usually do not require treatment other than close observation, but identify and treat the underlying cause for the pneumothorax.
  • For symptomatic pleural effusion, do needle aspiration; if empyema, insert large bore chest tube drainage. See Effusion and Empyema.

REFERRAL

  • Patients not improving within 48 hours of initiating second line therapy should be discussed with a paediatrician.
  • For possible ICU care if not maintaining saturations in normal range on oxygen or if clinical features of fatigue.

PNEUMONIA, VIRAL INFECTION

J12.9

DESCRIPTION

The commonest cause of pneumonia in children is viral infection. Respiratory syncyctial virus, adenovirus, cytomegalovirus, influenza, parainfluenza, adenovirus, herpes, human metapneumovirus and measles are the common viruses responsible for infections of the respiratory tract. Children present with fever, cough, rhinorrhea and chest in-drawing. Scattered fine crackles may also occur.

DIAGNOSTIC CRITERIA

  • As for pneumonia, see Pneumonia above.
  • It is not possible to discriminate viral from bacterial pneumonia on clinical or radiological grounds,
  • Chest X-ray is not routinely indicated.

GENERAL AND SUPPORTIVE MEASURES

  • Maintain nutrition.
  • Maintain hydration.

MEDICINE TREATMENT

Only if saturation < 92%:

  • Oxygen, humidified, 1–2 L/min via nasal prongs or nasal cannula.

To relieve discomfort:

  • Paracetamol, oral, 15 mg/kg/dose 6 hourly.

There is no role for routine antiviral therapy.

Empiric antibiotic therapy

Monitor for secondary bacterial infection. In most instances children will be treated with empiric antibiotics for pneumonia as in the section above.

REFERRAL

  • Patients not improving within 48 hours of admission should be discussed with a paediatrician.
  • For possible ICU care if not maintaining saturations in normal range on oxygen or if clinical features of fatigue.

PNEUMONIA DUE TO ANAEROBIC INFECTION

DESCRIPTION

Often seen in comatose patients with aspiration syndromes.

MEDICINE TREATMENT

Empiric antibiotic therapy for at least 7 days.

  • Ampicillin, IV, 25 mg/kg/dose, 6 hourly.

PLUS

  • Gentamicin, IV, 6 mg/kg/day as a single daily dose.

PLUS

  • Metronidazole, IV, 7.5 mg/kg/dose, 8 hourly.

Change antibiotics according to culture and sensitivity results.

PNEUMONIA IN HIV EXPOSED OR INFECTED CHILDREN

DESCRIPTION

In addition to common bacterial, fungal and viral pathogens causing pneumonia, opportunistic micro-organisms in a ‘polymicrobial mix’ are common in these children. Many of these children may fail to respond to the standard antibiotic treatment for pneumonia. Micro-organisms commonly involved are:

  • P. jiroveci (PJP) ,
  • cytomegalovirus,
  • Mycobacteria, e.g. M. tuberculosis
  • Non-typhoidal Salmonella,
  • S. aureus ,
  • Klebsiella pneumonia ,
  • S. pneumonia ,
  • Candida.

S. pneumonia, S. aureus and gram negative bacteria e.g. Klebsiella pneumoniae and Non-Typhoid Salmonella cause a significant proportion of HIV-related pneumonia in early childhood.

P. jiroveci (PJP)

  • PJP is a common fungal infection of the lung in infants from 2–6 months.
  • Presents as an acute onset of respiratory distress with minimal/absent chest signs in a child who is HIV exposed or infected.
  • Hypoxaemia and cyanosis are common features in severe disease.
  • Chest X-ray shows a range of abnormalities including bilateral perihilar interstitial changes.

Perinatal acquired cytomegalovirus associated pneumonia in HIV infected infants

  • Presents as an interstitial pneumonitis with acute hypoxic respiratory failure.
  • It may present as a multisystem sepsis-like syndrome, with hepatitis, neutropenia, pneumonitis, colitis and thrombocytopaenia.
  • Often occurs in children who are severely immunosuppressed (CDC Immune category 3) and carries a significant mortality.
  • The risk of CMV transmission through breastfeeding is low and therefore not a contraindication to breast feeding,
  • CMV co-infection occurs commonly as polymicrobial infection with PJP and bacteria.

Tuberculosis in HIV infected children

  • Occurs in children at all ages.
  • The diagnosis is difficult to confirm.
  • A Mantoux test of ≥ 5 mm induration is indicative of tuberculosis infection.

Fungal pneumonia

  • In addition to PCP described above various fungi, most commonly Candida and Aspergillus may cause pneumonia in immunocompromised children.
  • Confirmation of the diagnosis relies on microscopy and culture.
  • Serum markers may be useful in some cases.

HIV infected children with chronic lung disease

  • Often presents with lymphoid interstitial pneumonitis and bronchiectasis.
  • Secondary infection with bacteria similar to those seen in acute pneumonia are commonly isolated from these children.

DIAGNOSTIC CRITERIA

Investigations

  • Chest X-ray.
  • Screen for HIV infection:
    • In children < 18 months utilising HIV PCR testing.
    • In children > 18 months HIV ELISA (screening and confirmatory).
  • Investigate for PCP:
    • Immunofluorescence and silver methenamine staining on induced sputum sample.
  • Screen children with very severe pneumonia immediately for CMV using CMV viral load, where available.
    • A viral load of > 10 000 copies/mL suggests CMV disease: treat.
    • A viral load below 10 000 copies/mL is regarded as CMV infection: no therapy recommended.
  • Fungal infection:
    • Request MCS for fungi (blood or sputum).
  • Tuberculosis:

GENERAL AND SUPPORTIVE MEASURES

  • Avoid exposure to infectious agents.
  • Adequate nutrition.
  • Monitor oxygen saturations.
  • Restrict fluid intake.

MEDICINE TREATMENT

If saturation < 92%:

  • Oxygen, via nasal prongs or nasal cannula.

Treat for very severe bacterial pneumonia. See Pneumonia.

In all infants between 2 and 6 months with pneumonia consider PJP.
ADD

  • Co-trimoxazole, IV/oral, 5 mg trimethroprim/25 mg sulphamethoxazole /kg/dose, 6 hourly for 21 days.
    • Continue co-trimoxazole prophylaxis at the end of this treatment period until CD4 count recovers to normal.

Children who remain hypoxic on oxygen with proven or highly suspected PJP:

  • Prednisone, oral, 1–2 mg, daily for 7 days.
    • Taper dose over the next 7 days.

For confirmed CMV disease:

  • Ganciclovir, IV, 5 mg/kg 12 hourly until oral is tolerated;

THEN

  • Valganciclovir, oral, 16 mg/kg 12 hourly to complete the first 21 days of therapy;

THEN

  • Valganciclovir, oral, 16 mg/kg daily to complete 42 days of therapy.

For suspected or confirmed fungal pneumonia (other than PJP):

  • Amphotericin B deoxycolate, IV, 0.6–1.0 mg/kg as a single daily dose infused over 4 hours for at least 14 days.

Prehydration before administering amphotericin to prevent renal impairment:

  • Sodium chloride 0.9%, IV, 20 mL/kg plus potassium chloride, 20 mmol/L infused over 2–4 hours.

OR

  • Fluconazole, IV/oral, 10 mg/kg as a single daily dose for at least 14 days.

REFERRAL

  • Not responding to medicine therapy.
  • In cases of CMV disease for follow up for hearing deficit.

PNEUMONIA, NOSOCOMIAL

J18.9

DESCRIPTION

Children acquiring pneumonia 48–72 hours after hospitalisation.

The common pathogens are:

  • ß-lactamase producing pathogens,
  • extended spectrum ß-lactamase producing Klebsiella pneumoniae ,
  • P. aeruginosa ,
  • multidrug resistant Acinetobacter species,
  • methicillin resistant S. aureus ,
  • respiratory viruses e.g. respiratory syncytial virus, adenovirus, influenza, herpes, measles, parainfluenza.

GENERAL AND SUPPORTIVE MEASURES

  • Sepsis screen including blood cultures.

MEDICINE TREATMENT

Empirical antibiotic therapy

  • Broad spectrum antibiotics according to local susceptibility patterns.
  • Manage children with underlying predisposing factors according to the susceptibility of the most likely pathogen.
  • Review antibiotic choice once culture and sensitivity results become available.

For bacterial infections
Empiric therapy in the absence of local data:

  • Piperacillin/tazobactam, IV, 100 mg/kg/dose 8 hourly.

PLUS

  • Amikacin, IV, 15 mg/kg/dose, daily.

Adjust therapy according to sensitivities.

For methicillin resistant S. aureus pneumonia:

  • Vancomycin, IV, 15 mg/kg/dose 6 hourly infused over 1 hour.

BRONCHIOLITIS

J21.9

DESCRIPTION

Bronchiolitis is an acute viral infection of the small airways of the lower respiratory tract affecting children between 4 months and 2 years of age.
The most common pathogen is the respiratory syncytial virus.
Recurrent episodes of wheeze associated with bronchiolitis may occur, and some of these children may develop asthma.

Risk factors for severe bronchiolitis:

  • Age less than 3 months
  • Ex-preterm infants
  • Chronic lung disease
  • Congenital heart disease

DIAGNOSTIC CRITERIA

  • Prodrome of viral infection: irritability and rhinorrhoea.
  • A wheeze that is slowly responsive or non-responsive to bronchodilators.
  • Crepitations and signs of hyperinflation of the chest.
  • Chest X-ray should be reserved for clinically severe or complicated cases.
  • Tachypnoea: age dependent:
Age Respiratory rate
< 60 days > 60/minute
2-12 months > 50/minute
1-5 years > 40/minute

Bronchiolitis (mild)

  • Cough and fast breathing (tachypnoea).

Bronchiolitis (moderate)
Above plus one of the following:

  • lower chest wall in-drawing;
  • nasal flaring;
  • grunting.

Bronchiolitis (severe)
Above plus at least one of the following:

  • central cyanosis, oxygen saturation < 90% in room air;
  • inability to feed;
  • convulsions, lethargy or decreased level of consciousness;
  • severe respiratory distress (e.g. very severe chest wall in-drawing).

Mild cases, without risk factors are managed as outpatients. Provide counselling to the caregiver and devise a plan for the eventuality that the child deteriorates or does not improve. Mild cases with risk factors, moderate and severe cases require admission.

GENERAL AND SUPPORTIVE MEASURES

  • Isolate from other infants, if possible.
  • Patients with signs of moderate or severe disease or associated complications or underlying cardiorespiratory disorders should be hospitalised for monitoring of:
    • breathing pattern (apnoea monitoring if < 3 months of age),
    • heart rate and respiratory rate,
    • temperature,
    • SaO₂ ,
    • hydration and nutrition,
    • IV maintenance fluid if oral/nasogastric feeds/fluids are not tolerated. Avoid overhydration.

MEDICINE TREATMENT

For all hospitalised patients

Only if saturation < 92%:

  • Oxygen, humidified, 1–2 L/min via nasal prongs or nasal cannula.
    • Ensure clear nasal passages and correctly position the nasal prongs.

In children with recurrent wheezing, nebulise with a β₂ agonist, if there is a response consider asthma, see Conditions with predominant wheeze .

Antibiotic therapy

Routine antibiotic therapy is not indicated. Only use antibiotics if there is concern about bacterial co-infection.

For bacterial co-infection:

  • Amoxicillin, oral, 45 mg/kg/dose, 12 hourly for 5 days.

REFERRAL

  • Discuss all severe cases with a paediatrician.