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

Contents
IDENTITY............................................................................................................................................
PHYSICAL EXAMINATION (April 5th 2015)......................................................................................
General Status....................................................................................................................................
Antropometry Status..........................................................................................................................
Head to Toe Examination...................................................................................................................
Neurological Examination...............................................................................................................
Meningeal Sign............................................................................................................................
Motoric Examination...................................................................................................................
Autonom Examination.................................................................................................................
Laboratory Investigation..............................................................................................................
FOLLOW UP..................................................................................................................................
LITERATURE REVIEW.....................................................................................................................
DEFINITION..................................................................................................................................

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

PATHOPHYSIOLOGY.........................................................................................
...............17
CLINICAL MANIFESTATIONS....................................................................................................
DIAGNOSIS....................................................................................................................................
TREATMENT.................................................................................................................................
PREVENTION................................................................................................................................
REFERENCES....................................................................................................................................

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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 patients
mother).
Chief complain : Fever since 5 days before admission to the hospital.
Additional complains : Cough, shortness of breath,vomit.

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,

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fever felt up and down, reaches normal temperature. Patients 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

Thypoid

Worms

Surgery

Brain Concussion

Fracture

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Drug Reaction

Birth History
Mothers 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.
Childs 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

Prone Position

Food Self

Sitting

: 5 months old
: 5 6 months old
: 6 months old

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 Mental Status: Normal

Conclusion: Growth and development status is still in the normal limits
and was appropriate according to the patients age
History of Eating

Breast Milk : Exclusively 6 month.

Formula milk : -

Baby biscuits : Biscuits milna

Fruit and vegetables : Banana, Carrots

Immunization History
Immunization

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

Hib

4 times

0, 2, 4, 6 months old
2, 4, 6, months old

Family History

Patients 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

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Childbirth

Gender

Spontan pervaginam,
gestation aterm

Age

Boy

Age Died

Sumption Died

6 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
Awareness
Pulse
Breathing rate
Temperature

: mild ill
: Compos Mentis
: 123 x/min, regular, full, strong.
: 36x/min
: 38,8oC (per axilla)

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Antropometry Status
- Weight
- Height

: 7,3 kilogram
: 70 cm

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)
Conclusion: The patient has good nutritional status.

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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
ii.
iii.
iv.
1.
2.

i.

not visible
Palpation
: mass (-), tactile fremitus +/+
Percussion
: sonor on left lungs
Auscultation :
Cor
: regular S1-S2, murmur (-), gallop (-)
Pulmo : vesicular +/+, Wheezing -/- , Rhonchy +/+
Abdomen
:
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 (-)
iv. Auscultation : normal bowel sound, bruit (-)

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Vertebra

not look any mass along the line of the vertebral

Ekstremities : warm, capillary refill time < 2 second, edema(-)
Skin
: Good turgor.

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

Neurological Examination
Meningeal Sign

Motoric Examination
Power
Hand
Feet
Tonus
Hand
Feet
Trophy
Hand
Feet
Physiologic Reflex
Upper extrimities
Biceps
Triceps
Lower extrimities
Patella
Achilles

5 5 5 5/ 5 5 5 5
5 5 5 5/ 5 5 5 5
Normotonus / Normotonus
Normotonus / Normotonus
Normotrophy / Normotrophy
Normotrophy / Normotrophy
+/+
+/+
+/+
+/+

Pathologic Reflex
Upper extrimities
Hoffman
Trommer

-/-/-

Lower extrimities
Babinsky

-/12
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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/L

5,000 10,000/L

Hematocrits
Trombocytes

30 %
365.000/ L

40 48 %
150,000 400,000/L

Erythrocytes

4,07 million/L

4 5 million/L

WORKING DIAGNOSIS
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

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Ventolin (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 (+)

General condition: Compos mentis.

Heart rate
= 112 x/min
Respiratory rate = 34x/min
Temperature
= 37,3C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi +/+, wheezing -/-

Bronchopneumoni
DD/ Bronchiolitis

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O2 1L/m
IVFD Kaen3B, micro drip, 750cc / 24 Hours.
Inj. Cefotaxime 2x350 mg IV
Inj. Dexamet 3x1 mg IV
Paracetamol syr 3 x 0,7 cc
Inhalation twice a day
Ventolin (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc

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

S

Fever (+)
Phlegm (+)
Breathlless (+)
Productive cough (+)

General condition: Compos Mentis

Heart rate
= 120 x/min
Respiratory rate = 30x/min
Temperature
= 38.5C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : retraction (+) vesiculer +/+, rhonchi +/+, wheezing -/-

Bronchopneumoni

O2 1L/m
IVFD Kaen3B, micro drip, 750cc / 24 Hours.
Inj. Cefotaxime 2x350 mg IV
Inj. Dexamet 3x1 mg IV
Paracetamol syr 3 x 0,7 cc
Inhalation twice a day
Ventolin (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc

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

S

Fever (+)
Phlegm (+)
Productive cough (+)

General condition: Compos mentis.

Heart rate
= 110 x/min
Respiratory rate = 30x/min
Temperature
= 37C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi +/+, wheezing -/-

Bronchopneumoni

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

Inj. Cefotaxime 2x350 mg IV
Inj. Dexamet 3x1 mg IV
Paracetamol syr 3 x 0,7 cc
Inhalation twice a day
Ventolin (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc

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

S

Fever (-).
Productive cough (+)

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General condition: Compos mentis (+)

Heart rate
= 100 x/min
Respiratory rate = 26x/min
Temperature
= 36,2C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi +/+, wheezing -/-

Bronchopneumonia

Patient go home
IVFD Kaen3B, micro drip, 750cc / 24 Hours.
Inj. Cefotaxime 2x350 mg IV
Inj. Dexamet 3x1 mg IV
Paracetamol syr 3 x 0,7 cc
Inhalation twice a day
Ventolin (1,25 mg)
Bisolvon 3 drops
NaCl 1 cc

LITERATURE REVIEW
DEFINITION
Pneumonia (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:

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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.

ETIOLOGY
Pneumonia is caused by a number of infectious agents, including viruses, bacteria
and fungi. The most common are:

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

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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.

PATHOPHYSIOLOGY
Transmission
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 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.

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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

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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 1
Age-specific criteria for tachypnea

Age

Approximate normal
respiratory rates
(breaths/min)

Upper limit that should be used

to define
tachypnea (breaths/min)

<2
months

3450

60

212

2540

50

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months

15 years

2030

40

>5 years

1525

30

Physical signs suggesting consolidation include dullness to percussion, increased

tactile fremitus, reduced normal vesicular breath sounds and increased bronchial
breath sounds all 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.

DIAGNOSIS
Children 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

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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
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.

TREATMENT
Pneumonia should be treated with antibiotics. The antibiotic of choice is
amoxicillin dispersable tablets. Most cases of pneumonia require oral antibiotics,
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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
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.

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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
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.

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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
Chlindamycin 9.2 0.4 0.4

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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

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

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

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For inpatient management of children with severe pneumonia, the following

antibiotic therapy is recommended.
1st line lactams drugs: Benzlypenicillin, Amoxycillin, Ampicillin,AmoxycillinClavulanate
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

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

Prevention
Preventing 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.

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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
3.http://dx.doi.org/10.5772/54052 163 [2] Singh V, Aneja S. Pneumonia
management in the developing World. Pediatr Respir Rev 2011;12:5259
4.Rahajoe Nastiti N, Supriyanto Bambang, dkk. Pneumonia. Buku Ajar
Respirologi Anak. Edisi Pertama. Jakarta : Badan Penerbit IDAI. Th;
2010.hal; 351-363

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