Community acquired
pneumonia is the leading killer of children under the age of 5 years. In ER, a diagnosis of
pneumonia may be made and the severity graded on basis of WHO's classification for
pneumonia in children up to 5 years of age. It relies on age-specific respiratory rate, presence of lower chest indrawing and signs of severe illness. A diagnosis of
pneumonia is made if a febrile child has history of
cough and difficult or rapid breathing and a respiratory rate above age specific threshold; however, signs of
airway obstruction should be ruled out. Severe
pneumonia is diagnosed if with the above features lower chest wall retraction is present; nonetheless, all infants below 2 months and children with moderate to severe
malnutrition with
pneumonia are categorized as having severe
pneumonia. A chest radiograph is indicated only if the diagnosis is in doubt; complications are suspected and there is severe/very severe or recurrent
pneumonia. Non-severe
pneumonia is treated at home with oral
amoxicillin for 3-5 days. If there is no improvement in 48 h it is changed to
amoxicillin-
clavulanate.
Azithromycin is added for atypical
pneumonia. Indications for hospitalization include age <2 months, treatment failure on oral
antibiotics, severe/very severe or recurrent
pneumonia,
shock,
hypoxemia, severe
malnutrition, immunocompromised state. Severe
pneumonia is treated with
injectable ampicillin;
Cloxacillin is added if clinical/radiographic features suggest
Staphylococcal infection. On review after 48 h, if improved, the child may be sent home on oral
amoxicillin for 5 more days; if not, it is treated as very severe
pneumonia. Very severe
pneumonia is treated with
injectable Ampicillin plus
gentamicin. If improved after 48 h, oral
amoxicillin and
gentamicin are continued for 10 days. If not, respiratory support is enhanced,
antibiotics are changed to intravenous
ceftriaxone and
amikacin and further work up is planned. Children with
chronic diseases and recurrent
pneumonia require specific
antibiotics depending on the underlying cause.