case tami (bp)-3

CASE PRESENTATION

“BRONCHOPNEUMONIA”

Mentor :

dr. Ulynar Marpaung, Sp. A

Written by :

Julianti Mulya Utami 1102010138

Faculty of Medicine Yarsi

Pediatric Department

Rumah Sakit Bhayangkara tk.I R.S. Sukanto-Jakarta

Periode: 16 March – 23 May 2015

ContentsIDENTITY...............................................................................................................................................2

PHYSICAL EXAMINATION (April 5th 2015).......................................................................................7

General Status......................................................................................................................................7

Antropometry Status............................................................................................................................8

Head to Toe Examination....................................................................................................................9

Neurological Examination.................................................................................................................10

Meningeal Sign..............................................................................................................................10

Motoric Examination.....................................................................................................................10

Autonom Examination...................................................................................................................11

Laboratory Investigation................................................................................................................11

FOLLOW UP.....................................................................................................................................12

LITERATURE REVIEW......................................................................................................................16

DEFINITION.....................................................................................................................................16

ETIOLOGY..........................................................................................................................16

PATHOPHYSIOLOGY........................................................................................................17

CLINICAL MANIFESTATIONS.....................................................................................................20

DIAGNOSIS......................................................................................................................................21

TREATMENT...................................................................................................................................22

PREVENTION..................................................................................................................................29

REFERENCES......................................................................................................................................30

IDENTITY

Patient

Name : FAH

Birth Date : October 10th 2014

Age : 6 months

Gender : Male

Address : Ketapang , Munjul

Nationality : Indonesia

Religion : Islam

Date of admission: April 4th 2015

Date of examination: April 10th 2015

Father Mother

Name Mr. T Mrs. M

Age 28 years old 25 years old

Job Entrepreneur Housewife

Nationality Javanese Javanese

Religion Islam Islam

Education High School (graduated)s High School (graduated)s

Earning/month Approximately Rp.2.000.000,- -

Address Ketapang, Munjul.

ANAMNESIS

The anamnesis was taken on April 5th 2015, by alloanamnesis (from patient’s mother).

Chief complain : Fever since 5 days before admission to the hospital.

Additional complains : Cough, shortness of breath,vomit.

3

History Of Present Ilness

A 6 months old child came to Raden Said Sukanto Police Center Hospital emergency

room suffering from fever since 5 days before admission the hospital, fever felt up and down,

reaches normal temperature. Patient’s mother also complaining cough continuously since 6

months before admitted. Cough had been healed, then relaps 5 days before admitted. Other

complaint is vomiting after eat something, phlegm, and hard to breath.

1 day before hospital admission, the child got fever at morning with the 390 C

temperature. Then her mother gave febrifuge. After receiving treatment, the child still fever.

On the admission hospital day, the child still fever and there are shortness of breath. His

father has history of asthma.

History Of Past Illness

Pharyngitis/

Tonsilitis

-

Bronchitis -

Pneumonia -

Morbilli -

Pertussis -

Varicella -

Diphteria -

Malaria -

Polio -

Enteritis -

Bacillary Dysentry -

Amoeba Dysentry -

Diarrhea -

4

Thypoid -

Worms -

Surgery -

Brain Concussion -

Fracture -

Drug Reaction -

Birth History

Mother’s Pregnancy History

The mother routinely checked her pregnancy to the doctor in the hospital. She denied any

problem noted during her pregnancy. She took vitamins routinely given.

Child’s Birth History

Labor : Hospital

Birth attendants : Doctor

Mode of delivery : pervaginam

Gestation : 38 weeks

Infant state : healthy

Birth weight : 3400 grams

Body length : 50 cm

According to the mother, the baby started to cry and the baby's skin is red, no

congenital defects were reported

Development History

First dentition: 6 months

Psychomotor development

Head Up : 1 month old

Smile : 1 month old

Laughing : 1- 2 month old

Slant : 2,5 months old

Speech Initation : 5 months old

5

Prone Position : 5 months old

Food Self : 5 – 6 months old

Sitting : 6 months old

Mental Status: Normal

Conclusion: Growth and development status is still in the normal limits and was

appropriate according to the patient’s age

History of Eating

Breast Milk : Exclusively 6 month.

Formula milk : -

Baby biscuits : Biscuits milna

Fruit and vegetables : Banana, Carrots

Immunization History

Immunizatio

n

Frequency Time

BCG 1 time 1 month old

Hepatitis B 3 times 0, 1, 6 months old

DPT 3 times 2, 4, 6 months old

Polio 4 times 0, 2, 4, 6 months old

Hib 4 times 2, 4, 6, months old

Family History

Patient’s both parents were married when they were 26 years old and 24 years old,

and this is their first marriage.

There are not any significant illnesses or chronic illnesses in the family declared.

History of her brothers

6

Childbirth Gender Age Age Died Sumption Died

Spontan pervaginam,

gestation aterm

Boy6 months old

- -

Born died : ( - )

Child dies : ( - )

Miscarriage : ( - )

History of Disease in Other Family Members / Around the House

There is no one living around their home known for having the same condition as the patient.

Sosial and Economic History

The patient lived at the house with size 20 m x 10 m together with father and mother.

There are 1 door at the front side, 1 toilet near the kitchen and 3 rooms, in which 1

room is the bedroom of three of them and 1 room is for guest. There are 4 windows

inside the house. The windows are occasionally opened during the day.

Hygiene:

o The patient changes his clothes everyday with clean clothes.

o Bed sheets changed every two weeks.

PHYSICAL EXAMINATION (April 5th 2015)

General Status

- General condition : mild ill

- Awareness : Compos Mentis

- Pulse : 123 x/min, regular, full, strong.

- Breathing rate : 36x/min

- Temperature : 38,8oC (per axilla)

Antropometry Status

- Weight : 7,3 kilogram

- Height : 70 cm

7

Nutritional Status based NCHS (National Center for Health Statistics) year 2000:

WFA (Weight for Age): 7,3/7,5 x 100 % = 97 % ( good nutrition)

HFA (Height for Age): 70/68 x 100 % = 102 % (good nutrition)

WFH (Weight for Height): 7,5/9 x 100 % = 85 % (normal)

8

Conclusion: The patient has good nutritional status.

Head to Toe Examination

Head

Normocephaly, hair (black, normal distributon, not easily removed ) sign of trauma (-),

sunken fontanelle (+).

Eyes

Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation -/-,

sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light response ++/++

Ears

Normal shape, no wound, no bleeding ,secretion or serumen

Nose

Normal shape, midline septum, secretion -/-

Mouth

Lips: moist

Teeth: no caries

Mucous: moist

Tongue: Not dirty

Tonsils: T1/T1, No hyperemia

Pharynx: hyperemia (+)

Neck

Lymph node enlargement (-), scrofuloderma (-)

Thorax :

i. Inspection : symmetric when breathing , no retraction, ictus cordis is not visible

ii. Palpation : mass (-), tactile fremitus +/+

iii. Percussion : sonor on left lungs

iv. Auscultation :

1. Cor : regular S1-S2, murmur (-), gallop (-)

2. Pulmo : vesicular +/+, Wheezing -/- , Rhonchy +/+

Abdomen :

i. Inspection : Convex, epigastric retraction (-), there is no a widening of the veins, no

spider nevi.

ii. Palpation : supple, liver and spleen not palpable, fluid wave (-),abdominal mass (-)

iii. Percussion : The entire field of tympanic abdomen, shifting dullness (-)

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iv. Auscultation : normal bowel sound, bruit (-)

Vertebra : There does not appear scoliosis, kyphosis, and lordosis, do not look

any mass along the line of the vertebral Ekstremities : warm, capillary refill time < 2 second, edema(-)

Skin : Good turgor.

Neurological Examination

Meningeal Sign

Motoric Examination

Power

Hand

Feet

5 5 5 5/ 5 5 5 5

5 5 5 5/ 5 5 5 5

Tonus

Hand

Feet

Normotonus / Normotonus

Normotonus / Normotonus

Trophy

Hand

Feet

Normotrophy / Normotrophy

Normotrophy / Normotrophy

Physiologic Reflex

Upper extrimities

Biceps

Triceps

Lower extrimities

Patella

+ / +

+ / +

+ / +

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Achilles + / +

Pathologic Reflex

Upper extrimities

Hoffman

Trommer

Lower extrimities

Babinsky

Chaddock

Oppenheim

Gordon

Schaeffer

- / -

- / -

- / -

- / -

- / -

- / -

- / -

Clonus

Patella

Achilles

- / -

- / -

Autonom Examination

Defecation

Urination

Sweating

Normal

Normal ( 4-5 times daily )

Normal

Laboratory Investigation

Hematology April 4th 2015

Hematology Results Normal Value

Haemoglobin 10 g/dL 13-16 g/dL

Leukocytes 11.500/µL 5,000 – 10,000/µL

Hematocrits 30 % 40 – 48 %

Trombocytes 365.000/ µL 150,000 – 400,000/µL

Erythrocytes 4,07 million/µL 4 – 5 million/µLWORKING DIAGNOSIS

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Bronchopneumonia

DD/ Bronchiolitis

MANAGEMENT

O2 1L/m

IVFD RL 750cc / 24 Hours.

Inj. Cefotaxime 2x350 mg IV

Inj. Dexamethasone 3 x 1 mg IV

PCT syrup 3x0,6 cc

Inhalation : twice a day

Ventolin ½ (1,25 mg)

Bisolvon 3 drops

NaCl 1 cc

PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam

Quo ad sanactionam : dubia ad bonam

FOLLOW UP April 5th 2015 - April 10th 2015.

April 5th 2015. Second day of hospitalization, 7th day of illness

S Fever (+)

Phlegm (+)

Breathless (+)

Productive cough (+)

O General condition: Compos mentis.

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Heart rate = 112 x/min

Respiratory rate = 34x/min

Temperature = 37,3˚C

Cardio : S1/S2, reguler, no murmur, no gallop

Pulmonary : vesiculer +/+, rhonchi +/+, wheezing -/-

A Bronchopneumoni

DD/ Bronchiolitis

P - O2 1L/m

IVFD Kaen3B, micro drip, 750cc / 24 Hours.


Inj. Dexamet 3x1 mg IV

Paracetamol syr 3 x 0,7 cc

Inhalation twice a day


Bisolvon 3 drops

NaCl 1 cc

April 6th 2015. Third day of hospitalization, 8th day of illness

S Fever (+)

14

Phlegm (+)

Breathlless (+)


O General condition: Compos Mentis



Temperature = 38.5˚C


Pulmonary : retraction (+) vesiculer +/+, rhonchi +/+, wheezing -/-

A Bronchopneumoni

P - O2 1L/m







Bisolvon 3 drops

NaCl 1 cc

April 7th 2015, Fourth days of hospitalization, 9th day of illness

S Fever (+)

Phlegm (+)


O General condition: Compos mentis.


15


Temperature = 37˚C



A Bronchopneumoni

P IVFD Kaen3B, micro drip, 750cc / 24 Hours.






Bisolvon 3 drops

NaCl 1 cc

April 9th 2015. Fifth of hospitalization, 11th day of illness

S Fever (-).


O General condition: Compos mentis (+)



Temperature = 36,2˚C



A Bronchopneumonia

P Patient go home



16





Bisolvon 3 drops

NaCl 1 cc

LITERATURE REVIEW

DEFINITIONPneumonia (pneumonitis) is an inflammatory process in lung parenchyma usually associated

with a marked increase in interstitial and alveolar fluid. Advances in antibiotic therapy have

led to the perception that pneumonia is no longer a major health problem in the United States.

Among all nosocomial infections (hospital acquired), pneumonia is the second most

common, but has the highest mortality. Pneumonia can be divided into three groups, which

guide management: community acquired, hospital or nursing home acquired (nosocomial),

and pneumonia in an immunocompromised person.

There are two clinical definitions of pneumonia:

1. Bronchopneumonia which is a febrile illness with cough, respiratory distress with evidence

of localised or generalised patchy infiltrates on chest x-ray

2. Lobar pneumonia which is similar to bronchopneumonia except that the physical findings

and radiographs indicate lobar consolidation.

ETIOLOGYPneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi.

The most common are:

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Streptococcus pneumoniae – the most common cause of bacterial pneumonia in

children;

Haemophilus influenzae type b (Hib) – the second most common cause of bacterial

pneumonia; respiratory syncytial virus is the most common viral cause of pneumonia;

in infants infected with HIV, Pneumocystis jiroveci is one of the commonest causes of

pneumonia, responsible for at least one quarter of all pneumonia deaths in HIV-

infected infants.

Age Bacterial Pathogens

Newborns : Group B streptococcus, Escherichia coli, Klebsiella species, Enterobacteriaceae

1- 3 months : Chlamydia trachomatis

Preschool : Streptococcus pneumoniae, Haemophilus influenzae type b, Staphylococcal aureus,

Less common: group A streptococcus, Moraxella catarrhalis, Pseudomonas aeruginosa

School : Mycoplasma pneumoniae, Chlamydia pneumoniae

Risk factors

While most healthy children can fight the infection with their natural defences, children

whose immune systems are compromised are at higher risk of developing pneumonia. A

child's immune system may be weakened by malnutrition or undernourishment, especially in

infants who are not exclusively breastfed.

Pre-existing illnesses, such as symptomatic HIV infections and measles, also increase a

child's risk of contracting pneumonia.

The following environmental factors also increase a child's susceptibility to pneumonia:

indoor air pollution caused by cooking and heating with biomass fuels (such as wood or

dung) living in crowded homes parental smoking.

PATHOPHYSIOLOGYTransmission

Pneumonia can be spread in a number of ways. The viruses and bacteria that are commonly

found in a child's nose or throat, can infect the lungs if they are inhaled. They may also

spread via air-borne droplets from a cough or sneeze. In addition, pneumonia may spread

18

through blood, especially during and shortly after birth. More research needs to be done on

the different pathogens causing pneumonia and the ways they are transmitted, as this is of

critical importance for treatment and prevention.

Presenting features

The presenting features of viral and bacterial pneumonia are similar. However, the symptoms

of viral pneumonia may be more numerous than the symptoms of bacterial pneumonia. In

children under 5 years of age, who have cough and/or difficult breathing, with or without

fever, pneumonia is diagnosed by the presence of either fast breathing or lower chest wall in

drawing where their chest moves in or retracts during inhalation (in a healthy person, the

chest expands during inhalation). Wheezing is more common in viral infections.

Very severely ill infants may be unable to feed or drink and may also experience

unconsciousness, hypothermia and convulsions.

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CLINICAL MANIFESTATIONS

The clinical diagnosis of pneumonia has traditionally been made using auscultatory findings such as bronchial breath sounds and crepitations in children with cough. However, the sensitivity of auscultation has been shown to be poor and varies between 33 %- 60% with an average of 50 % in children. Tachypnoea is the best single predictor in children of all ages. Measurement of tachypnoea is better compared with observations of retractions or auscultatory findings. It is nonetheless important to measure respiratory rate accurately. Respiratory rate should be counted by inspection for 60 seconds. However in the young infants, pneumonia may present with irregular breathing and hypopnea.

The symptoms of pneumonia may be nonspecific, especially in infants and younger children. Acute onset of fever, cough, difficulty breathing, poor feeding or vomiting, and lack of interest in normal activities are common. Chest or abdominal pain may be a prominent feature. Abrupt onset of rigors favours a bacterial cause. A significant, persistent cough may predominate in pneumonia caused by M pneumoniae. During influenza season, consider influenza, with or without a secondary bacterial component, as a cause of pneumonia.Children typically experience fever and tachypnea (determined by counting the respiratory rate for 60 s in a calm state; see Table 1). Indrawing, retractions and/or a tracheal tug will indicate respiratory distress (dyspnea). Decreased oxygen saturation indicates hypoxemia and should be measured in all hospital settings. Cyanosis will only be evident with very severe hypoxemia. Normal oxygen saturation does not exclude pneumonia, especially early in the course of the illness.TABLE 1Age-specific criteria for tachypnea

Age

Approximate normal respiratory rates(breaths/min)

Upper limit that should be used to definetachypnea (breaths/min)

<2 months 34–50 60

2–12 months 25–40 50

1–5 years 20–30 40

>5 years 15–25 30

Physical signs suggesting consolidation include dullness to percussion, increased tactile fremitus, reduced normal vesicular breath sounds and increased bronchial breath sounds – all

21

http://www.cps.ca/documents/position/pneumonia-management-children-youth#Table1

of which can be difficult to detect in young children. The presence of wheezing should suggest the possibility that radiographic changes may be due to atelectasis and mucous plugging from asthma or bronchiolitis rather than pneumonia. Signs of an effusion are dullness to percussion, decreased tactile fremitus, and decreased or absent breath sounds. There may be associated signs of dehydration and/or sepsis.

DIAGNOSISChildren with bacterial pneumonia cannot be reliably distinguished from those with viral

disease on the basis of any single parameter; clinical, laboratory or chest radiograph findings.

1. Chest radiograph

Chest radiograph is indicated when clinical criteria suggests pneumonia. It will not identify

the aetiological agent. However the chest radiograph is not always necessary if facilities are

not available or the pneumonia is mild.

2. Complete white blood cell and differential count.This test may be helpful as an increased

white blood count with predominance of polymorphonuclear cells may suggest bacterial

cause. However, leucopenia can either suggest a viral cause or severe overwhelming

infection.

3. Blood culture

Blood culture remains the non-invasive gold standard for determining the precise etiology of

pneumonia. However the sensitivity of this test is very low. Positive blood cultures are found

only in 10% to 30% of patients with pneumonia. Even in 44% of patients with radiographic

findings consistent with pneumonia, only 2.7% were positive for pathogenic bacteria. Blood

culture should be performed in severe pneumonia or when there is poor response to the first

line antibiotics.

4. Culture from respiratory secretions

It should be noted that bacteria isolates from throat swabs and upper respiratory tract

secretions are not representative of pathogens present in the lower respiratory tract. Samples

from the nasopharynx and throat have no predictive values. This investigation should not be

routinely done.

5. Other tests

22

Bronchoalveolar lavage is usually necessary for the diagnosis of Pneumocystis carini

infections primarily in immunosuppressed children. It is only to be done when facilities and

expertise are available. If there is significant pleural effusion diagnostic, pleural tap will be

helpful. Mycoplasma pneumoniae, Chlamydia, Legio nella and Moxarella catarrhalis are

difficult organisms to culture, and thus serological studies should be performed in children

with suspected atypical pneumonia. An acute phase serum titre of more than 1:160 or paired

samples taken 2-4 weeks apart showing four fold rise is a good indicator of Mycoplasma

pneumoniae infection. 17 This test should be considered for children aged five years or older

with pneumonia.

TREATMENTPneumonia should be treated with antibiotics. The antibiotic of choice is amoxicillin

dispersable tablets. Most cases of pneumonia require oral antibiotics, which are often

prescribed at a health centre. These cases can also be diagnosed and treated with inexpensive

oral antibiotics at the community level by trained community health workers. Hospitalization

is recommended only for severe cases of pneumonia, and for all cases of pneumonia in

infants younger than 2 months of age.

Guidelines for referral to hospital or hospital admission

Most children can be managed as outpatients. Specific criteria for admission are not available

for children. Hospitalization is generally indicated if the child is unable to eat or drink, has an

inability to comply with oral therapy, has a concerning social situation, dehydration,

hypotension, sepsis, oxygen saturations of lower than 92%, vomiting, tachypnea, chest

retractions, or any evidence of an empyema or lung abscess . There should be a low threshold

for admitting children younger than six months of age because it can be difficult for

caregivers to recognize deterioration.

I Assessment of severity of pneumonia

The predictive value of respiratory rate for the diagnosis of pneumonia is age specific

(Table 7)

Table 7: Definition of Tachypnoea

Less than 2 months > 60 /min

23

2- 12 months > 50 /min

12 months – 5 years > 40/ min

Assessment of severity is essential for optimal management of pneumonia. Pneumonia may

be categorized according to mild, severe, very severe based on the respiratory signs and

symptoms (Table 8 and Table 9)

Table 8: Assessment of severity of pneumonia in infants below two months old.

Severe pneumonia Severe chest indrawing or fast breathing

Very severe pneumonia Not feeding

Convulsions

Abnormally sleepy or difficult to wake

Fever/ low body temperature

Hypopnea with slow irregular breathing

Table 9: Assessment of severity of pneumonia in children age 2 months to 5 years old

Mild Pneumonia Fast breathing

Severe pneumonia Chest indrawing

Very severe pneumonia Not able to drink

Convulsions

Drowsiness

Malnutrition

Adapted from WHO

II Assessment of oxygenation

The best objective measurement of hypoxia is by pulse oximetry which avoids the need for

arterial blood gases. It is a good indicator of the severity of pneumonia

III Criteria for hospitalization

24

Community acquired pneumonia can be treated at home. It is crucial to identify indicators of

severity in children who may need admission as failure to do so may result in death. The

following indicators can be used as a guide for admission.

1. Children aged <3 months whatever the severity of pneumonia.

2. Fever (>38.50 C), refusal to feed and vomiting

3. Rapid breathing with or without cyanosis

4. Systemic manifestation

5. Failure of previous antibiotic therapy

6. Recurrent pneumonia

7. Severe underlying disorders ( i.e. immunodeficiency, chronic lung disease )

IV Antibiotic therapy

When treating pneumonia clinical, laboratory and radiographic findings should be

considered. The age of the child, local epidemiology of respiratory pathogens and sensitivity

of these pathogens to particular microbial agents and the emergence of antimicrobial

resistance also determine the choice of antibiotic therapy (Table 10 and Table 11) The

severity of the pneumonia and drug costs have also a great impact on the selection of therapy

(Table 5.7).

The majority of childhood infections are caused by viruses and do not require any antibiotic.

However, it is also very important to remember that we should be vigilant to choose

appropriate antibiotics especially in the initial treatment to reduce further mortality and

morbidity.

Table 10: Susceptibility (%) pattern of Streptococcus pneumoniae found in Malaysia 20

Antibiotic Susceptible Intermediate Resistance

Azithromycin 98.1 1.9

Cefuroxime 99.6 0.4

Chloramphenicol 95.1 1.5 3.4

25

Chlindamycin 9.2 0.4 0.4

Cotrimoxazole 86.4 3.9 9.7

Erythromycin 98.4 0.4 1.1

Penicillin 93.0 7.0

Tetracycline 78.2 0.8 21.0

Table 11: Predominant bacterial pathogens of children and the recommended

antimicrobial agents to be used.

Pathogens Antimicrobial agent

Beta- lactam susceptible

Streptococcus pneumonia Penicillin, Cephalosporins

Haemophilus influenzae type b Ampicillin,Chloramphenicol,

Cephalosporins

Staphylococcus aureus Cloxacillin

Group A Sreptococcus Penicillin,Cephalosporin

Mycoplasma pneumoniae Macrolides such as erythromycin and

Azithromycin

Chlamydia pneumoniae Macrolides such as erythromycin and

Azithromycin

Bordetella pertussis Macrolides such as erythromycin and

Azithromycin

Table 12: Commonly used antibiotics and their dosages

Intravenous Antibiotics Dosages

Amoxycillin-Clavulanate Acid 10-25mg/kg/dose 8 hrly

26

Ampicillin -sulbactam 10-25 mg/kg/dose 8 hrly

Ampicillin 100mg/kg/day 6 hrly

C. Penicillin 25,000-50,000U/kg/dose 6 hourly

Cefuroxime 10-25 mg/kg/dose 8 hrly

Cefotaxime 25-50mg/kg/dose 8 hrly

Cloxacillin 25-50mg/kg/dose 6hrly

Co-trimoxazole (trimethoprim ) 4 mg/kg/dose 12 hrly

Erythromycin 7.5mg kg/dose 6 hrly

Oral Antibiotis Dosages

Azithromycin 10-15 mg/kg/day daily dose

Augmentin 114 mg 12 hourly (less than 2 years)

228 mg 12 hourly (more than 2 years)

Cefuroxime 125 mg 12 hourly (less than 2 years)

250 mg 12 hourly (more than 2 years)

Cotrimoxazole 4 mg/kg/dose 12 hourly

Cloxacillin 50mg/kg /dose 6 hourly

Erythromycin Estolate 7.5 mg/kg/dose 12 hour ly

Penicillin V 7.5 - 15 mg/kg/dose 6 hourly

INPATIENT MANAGEMENT

I Antibiotic therapy

For inpatient management of children with severe pneumonia, the following antibiotic

therapy is recommended.

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1st line lactams drugs: Benzlypenicillin, Amoxycillin, Ampicillin,Amoxycillin-

Clavulanate

2nd line Cephalosporins : Cefotaxime, Cefuroxime, Ceftazidime,

3rd line Carbapenem: Imepenam

Others Aminoglycosides: Gentamicin, Amikacin

If there are no signs of recovery; especially if the patient remains toxic and ill with spiking

temperature for 48-72 hours, a 2nd of 3rd line antibiotic therapy need to be considered. If

Mycoplasma or Chlamydia species are the causative agents, a macrolide is the appropriate

choiceA child admitted to hospital with severe community acquired pneumonia must receive

parenteral antibiotics. As a rule, in severe cases of pneumonia, combination therapy using a

second or third generation cephalasporins and macrolide should be given. Staphylococcal

infections and infection caused by Gram negative organisms such as Klebsiella sp are more

frequently reported in malnourished children.

Staphyloccoccal infection

Staphylococcus aureus is responsible for a small proportion of acute respiratory infections in

children. Nevertheless a high index of suspicion is required because of the potential for rapid

deterioration. It is chiefly a disease of infants with a significant mortality rate. Radiological

features suggestive of Staphylococcal pneumonia include the presence of multilobar

consolidation, cavitation, pneumatocoeles, spontaneous pneumothorax, empyema and pleural

effusion. Treatment with high dose intravenous cloxacillin (200mg/kg.day) for a longer

duration and drainage of empyema will result in good outcome in the majority of cases.

II Supportive treatment

1. Fluid therapy

Oral intake should cease when a child is in severe respiratory distress. In severe pneumonia,

inappropriate secretion of anti-diuretic hormone is increased, dehydration is therefore

uncommon. It is important that the child should not be overhydrated.

2. Oxygen therapy

28

Oxygen reduces mortality associated with severe pneumonia. It should be given especially to

children who are restless, tachypnoea with severe chest indrawing, cyanosed or not tolerating

feeds. The SpO2 should be maintained above 95%.

3. Anti-tussive remedies

It is not recommended as it causes suppression of cough and may interfere with airway

clearance. Adverse effects and overdosa ge have been reported.

4. Chest physiotherapy

The function of chest physiotherapy is to assist in the removal of tracheobronchial secretions

resulting in an increase gas exchange and reduction in the work of breathing. However, trials

have found no clinically discernible benefit or impact of chest physiotherapy on the course of

illness in bronchiectasis, cystic fibrosis, pneumonia, bronchiolitis, asthma, acute atelectasis,

inhaled foreign body and post extubation babies. There is no evidence to suggest that chest

physiotherapy should be routinely performed in pneumonia

Penicillin allergy

If the previous suspected allergic reaction included an urticarial rash, hypotension or

bronchospasm, the reaction may have been immunoglobulin E (IgE) mediated and all beta

lactams should be avoided. For children with nonsevere pneumonia who are treated as

outpatients, clarithromycin and azithromycin are reasonable choices, while keeping in mind

that pneumococcal resistance to antimicrobials is increasingly common. For more severe

pneumonias with suspected IgE-mediated penicillin allergy, options should be discussed with

a paediatric infectious diseases physician. If the previous suspected allergic reaction did not

appear to be IgE mediated, cephalosporins can be used. Cefuroxime axetil can be used in

place of amoxicillin, while recognizing that pneumococcal coverage is inferior with these

drugs.

OUTPATIENT MANAGEMENT

In children with mild pneumonia, their breathing is fast but there is no chest indrawing. Oral

antibiotics at an appropriate dose for an adequate duration is effective for treatment27, 28, 29,

29

30, 31. The mother is advised to return in two days for reassessment or earlier if the child

appears to deteriorate.

PreventionPreventing pneumonia in children is an essential component of a strategy to reduce child

mortality. Immunization against Hib, pneumococcus, measles and whooping cough

(pertussis) is the most effective way to prevent pneumonia.

Adequate nutrition is key to improving children's natural defences, starting with exclusive

breastfeeding for the first 6 months of life. In addition to being effective in preventing

pneumonia, it also helps to reduce the length of the illness if a child does become ill.

Addressing environmental factors such as indoor air pollution (by providing affordable clean

indoor stoves, for example) and encouraging good hygiene in crowded homes also reduces

the number of children who fall ill with pneumonia.

In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk

of contracting pneumonia.

30

REFERENCES

1.World Health Organization. Pneumonia. Fact sheet No. 331.2011. Available at

www.who.int/mediacentre/factsheets/fs331/en. Accessed 03.08.2012 Pneumonia in Children

2.Garna H dan Heda M.2005. Pneumonia Dalam Pedoman Diagnosis Dan Terapi 3rd Ed : Bagian IKA

FK UNPAD Bandung.th ; 2010.Hal; 403 – 8

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Pertama. Jakarta : Badan Penerbit IDAI. Th; 2010.hal; 351-363

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case tami (bp)-3

Documents

hospital admission

months old child

admission hospital day

hospital birth attendants

development history

patients mother

month old smile

month old slant