Pneumonia

DESCRIPTION

Acute infection of the lung parenchyma, usually caused by bacteria, especially Streptococcus pneumonia (pneumococcus).

Management is guided by:

  • age
  • co-morbidity
  • severity of the pneumonia

Manifestations include:

  • malaise
  • fever, often with sudden onset and with rigors
  • cough, which becomes productive of rusty brown or yellow-green sputum
  • pleuritic type chest pain
  • shortness of breath
  • in severe cases, shock and respiratory failure.

On examination there is:

  • fever
  • crackles or crepitations
  • tachypnoea
  • bronchial breath sounds

There may be a pleural rubbing sound or signs of a pleural effusion.

Predisposing conditions include:

  • very young or old age
  • other concomitant diseases
  • malnutrition
  • HIV infection

Pneumococcal pneumonia often occurs in previously healthy adults.

Adults with mild to moderately severe pneumonia may be managed at PHC level, depending on the response to initial treatment (see below).

PNEUMONIA IN CHILDREN

J18.0-2/J18-9

DESCRIPTION

Pneumonia should be distinguished from viral upper respiratory infections. The most valuable sign in pneumonia is the presence of rapid breathing.

Assess the child for the severity of the pneumonia

Classify children according to the severity of the illness:

  • Pneumonia: fever, cough and rapid breathing, but no chest indrawing (of the lower chest wall) and no flaring of nostrils.
  • Severe pneumonia: fever, cough, rapid breathing, chest indrawing and flaring nostrils, or grunting.

Note: Children < 2 months of age with rapid breathing should be classified as having severe pneumonia.

Rapid breathing is defined as:

Age Respiratory rate
Birth – 2 months ≥ 60 breaths/minute
2–12 months ≥ 50 breaths/minute
1–5 years ≥ 40 breaths/minute

Danger signs indicating urgent and immediate referral include:

  • oxygen saturation of < 90% in room air
  • cyanosis
  • inability to drink
  • < 2 months of age
  • impaired consciousness
  • grunting

GENERAL MEASURES

  • Ensure adequate hydration.
  • Continue feeding.

MEDICINE TREATMENT

Pneumonia (non-severe):

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

LoEIII [27]

Weight
kg 		Dose
mg 		Use one of the following: Age
Months/years
Syrup mg/ 5mL Syrup mg/ 5mL Capsule
mg 		Capsule
mg
125 250 250 500
>3.5–5 kg 175 mg 7 mL 3.5 mL – – >1–3 months
>5–7 kg 250 mg 10 mL 5 mL – – >3–6 months
>7–11 kg 375 mg 15 mL 7.5 mL – – >6–18 months
>11–14 kg 500 mg – 10 mL 2 1 >18 months–3 years
>14–17.5 kg 750 mg – 15 mL 3 – >3–5 years
>17.5–25 kg 1000 mg – 20 mL* 4 2 >5–7 years
˃25–30 kg 1250 mg – 25 mL* 5 – ˃7–10 years
>30 kg 1500 mg – – 6 3 >10 years

*capsule/tablet preferred

Severe penicillin allergy (Z88.0)

Children

  • Macrolide, e.g:
  • Azithromycin, oral, 10 mg/kg/dose, daily for 3 days. See paediatric dosing tool.

Severe pneumonia:

  • Oxygen, using nasal cannula at 1–2 L/minute before and during transfer.
  • Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose. See paediatric dosing tool.
    • Do not inject more than 1 g at one injection site.

CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN

  • If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if jaundiced.
  • Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:
    • If ≤ 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone administered.
    • If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after.
    • Preferably administer IV fluids without calcium contents.
  • Always include the dose and route of administration of ceftriaxone in the referral letter.

REFERRAL

Urgent

  • All children with severe pneumonia, i.e. chest indrawing (of the lower chest wall), flaring nostrils or cyanosis.
  • All children < 2 months of age.

Non urgent

  • Inadequate response to treatment.
  • Children coughing for > 3 weeks to exclude other causes such as TB, foreign body aspiration or pertussis.

PNEUMONIA IN ADULTS

UNCOMPLICATED PNEUMONIA

J18.0-2/J18-9

DIAGNOSIS

A chest X-ray should ideally be taken in all patients to confirm the diagnosis. Send one sputum specimen for TB DNA PCR (Xpert MTB/RIF) to exclude pulmonary tuberculosis.

MEDICINE TREATMENT

If not severely ill (see referral criteria below):

  • Amoxicillin, oral, 1 g 8 hourly for 5 days.

Several Penicillin allergy: (Z88.0)

  • Moxifloxacin, oral, 400 mg daily for 5 days.

A follow-up chest X-ray should ideally be taken to ensure resolution of the pneumonia, in patients > 50 years of age.

LoEIII[28]

REFERRAL

Any of the following:

  • Confusion or decreased level of consciousness.
  • Cyanosis.
  • Respiratory rate of ≥ 30 breaths/minute.
  • Systolic BP < 90 mmHg.
  • Diastolic BP < 60 mmHg.
  • Deterioration at any point.
  • No response to treatment after 48 hours.
  • Patients with pneumonia:
    • from a poor socio-economic background
    • who are unlikely to comply with treatment
    • living a considerable distance from health centres
    • who have no access to immediate transport

PNEUMONIA IN ADULTS WITH UNDERLYING MEDICAL CONDITIONS OR > 65 YEARS OF AGE

J18.0-2/J18-9

A chest X-ray should ideally be taken in all patients to confirm the diagnosis. Send one sputum specimen for TB DNA PCR (Xpert MTB/RIF) to exclude pulmonary tuberculosis.

Common underlying conditions include:

  • Diabetes mellitus.
  • Alcoholism.
  • HIV infection.
  • Chronic liver disease.
  • Cardiac failure.
  • Chronic kidney disease.
  • COPD.

Most of these patients will require referral to a doctor.

MEDICINE TREATMENT

Mild pneumonia:

  • Amoxicillin/clavulanic acid 875/125 mg, oral, 12 hourly for 5 days.

Severe Penicillin allergy: (Z88.0)

  • Moxifloxacin, oral, 400 mg daily for 5 days.

A follow-up chest X-ray should ideally be taken to ensure resolution of the pneumonia, in patients > 50 years of age.

LoEIII:[29]

SEVERE PNEUMONIA

A follow-up chest X-ray should ideally be taken to ensure resolution of the pneumonia, in patients > 50 years of age.

J18.0-2/J18.8-9

DESCRIPTION

Severe pneumonia is defined as ≥ 2 of the following:

  • confusion/ decreased level of consciousness
  • respiratory rate of ≥30 breaths/ minute
  • > 65 years of age
  • systolic BP < 90 mmHg
  • diastolic BP < 60 mmHg

MEDICINE TREATMENT

While awaiting transfer:

  • Oxygen, to achieve a saturation of 92%.
  • Ceftriaxone, IV/IM, 1 g, as a single dose before referral.

CAUTION
Do not administer calcium containing fluids, e.g.
Ringer-Lactate, concurrently with ceftriaxone.

REFERRAL

Urgent

All patients.

PNEUMOCYSTIS PNEUMONIA

B20.6

DESCRIPTION

Interstitial pneumonia occurring with advanced HIV infection due to Pneumocystis jiroveci (formerly carinii ). Patients usually present with shortness of breath or dry cough. Chest X-ray may be normal in the early stages, but typically shows bilateral interstitial or ground glass pattern.

GENERAL MEASURES

Ensure adequate hydration.

MEDICINE TREATMENT

Adults

  • Cotrimoxazole, 6 hourly for 3 weeks.
Approx.
weight
kg 		Use one of
the following
tablets
80/400 mg 160/800 mg
< 40 kg 2 tablets 1 tablet
> 40 - 56 kg 3 tablets 1 and 1/2 tablet
> 56 kg 4 tablets 2 tablets

For secondary prophylaxis

  • Cotrimoxazole, oral, daily.
Use one of the following tablets
80/400 mg 160/800 mg
2 tablets 1 tablet

Discontinue cotrimoxazole prophylaxis if the CD4 count increases on ART to > 200 cells/mm³ for at least 6 months.

REFERRAL

  • All children.
  • Breathing rate > 24 breaths/minute.
  • Shortness of breath with mild effort.
  • Cyanosed patients.