PNEUMONIA

Question 1

History & Physical

Answer 1

Sudden onset fever, cough, tachypnea, pleuritic chest pain
abdominal pain may be a primary complaint

May be gradual onset cough, coryza, low grade fever in viral

Fever + Tachypnea, decreased breath sounds or fine crackles predicts PNA with 96%

All four variables sensitivity is 98%

Tachypnea most sensitive finding

Tachypnea, retractions, crackles, wheezing

Question 2

Clinical Features Infants and Young Children

Answer 2

Fever or hypothermia
Apnea
Tachypnea
Poor oral intake
Vomiting
Lethargy
Grunting

Include on differential even without respiratory symptoms

Question 3

Investigations

Answer 3

Primarily clinical diagnosis

Fever + Tachypnea, decreased breath sounds or fine crackles predicts PNA with 96%

All four variables sensitivity is 98%

Tachypnea most sensitive finding

CXR - not 100% sensitive or specific, not gold standard. Used to investigate complications of PNA or DDx

Consider NPS for respiratory viral panel + covid

For admission & Toxic:
CBC
Lytes
Cr
Blood Cultures

Question 4

CXR Features

Answer 4

Patchy or lobar infiltrate

Question 5

Management & Disposition: Neonates

Answer 5

Inpatient Management

Coverage for Grp b Strep, Grm -ve, Listeria

Ampicillin: 100-200 mg / kg / day IV divided q 8 h.

AND

Cefotaxime: 50 mg / kg / DOSE IV q 8 h. Max 2000 mg / dose.

Question 6

Management & Disposition: 1-3 months

Answer 6

Inpatient management

Coverage for Strep Pneumo, Chlamydia Trach, H. Flu, Staph Aureus

Ceftriaxone:
50-75 mg / kg / day IV divided q 12 h or 24 h. Max 2000 mg / day
OR
Vancomycin IV 40-60 mg/kg/day div q 12 (max 2 g/day)
Infuse over 1 hr. Order trough after 3rd dose.

+/- for atypicals
Azithromycin 10 mg / kg (max 500) once THEN 5 mg / kg (max 250 mg) q 24 h for 4 days

Question 7

Inpatient Management: 3 month - 5 years

Answer 7

Coverage for Strep PneumoH. Flu, Staph Aureus

Ampicillin: 100-200 mg / kg / day IV divided q 6 h. Max 2 g / day

OR

Ceftriaxone:
50-75 mg / kg / day IV divided q 12 h or 24 h. Max 2000 mg / day

OR

Vancomycin IV 40-60 mg/kg/day div q 12 (max 2 g/day)
Infuse over 1 hr. Order trough after 3rd dose.

+/- for atypicals
Azithromycin 10 mg / kg (max 500) once THEN 5 mg / kg (max 250 mg) q 24 h for 4 days

Question 8

Outpatient Management: Age 3 months - 5 yrs

Answer 8

Amoxicillin: 80-90 mg/kg/day PO divided q 8 hr

OR

Cefuroxime Axetil: 20-30 mg/kg/day PO divided bid. Max dose 1000 mg / day not great option, poor oral bioavailability

Question 9

Outpatient Management: Mycoplasma or Chlamydophilia Age 3 months - School Age

Answer 9

Azithromycin: Day 1, 10 mg / kg PO; Day 2-5, 5 mg / kg PO. Max 500 mg / day. 5 days total.

OR

Clarithromycin: 15 mg / kg / day divided bid for 7 days

Question 10

Outpatient Management: School Age - 18 yrs

Answer 10

Amoxicillin: 80-90 mg/kg/day PO divided tid

+/-

Azithromycin: Day 1, 10 mg / kg PO; Day 2-5, 5 mg / kg PO. Max 500 mg / day. 5 days total.

OR

Clarithromycin: 15 mg / kg / day divided bid for 7 days

Question 11

Inpatient Management: School Age - 18 yrs

Answer 11

Coverage for Strep Pneumo, C. Pneumonia, M. Pneumonia, H. Flu, Staph Aureus

Ampicillin: 100-200 mg / kg / day IV divided q 6 h. Max 2 g / day

OR

Ceftriaxone:
50-75 mg / kg / day IV divided q 12 h or 24 h. Max 2000 mg / day

OR

Vancomycin IV 40-60 mg/kg/day div q 12 (max 2 g/day)
Infuse over 1 hr. Order trough after 3rd dose.

+/- for atypicals
Azithromycin 10 mg / kg (max 500) IV once THEN 5 mg / kg (max 250 mg) IV q 24 h for 4 days

Question 12

Disposition: Admission Criteria

Answer 12

Toxic Appearance
Dehydration and Vomiting
Age < 3 months
Moderate respiratory distress (hypoxia, retractions, tachypnea)
Multilobar disease
Pleural Effusions
Impaired Immune Function
Concern about home environment, ability to follow up