All patients with pneumonia should be assessed for hypoxia, and oxygen provided if indicated. Cyanosis is often not present in hypoxic children. 28 Oxygen saturation correlates well with clinical outcome and length of hospital stay. 36 Children with an oxygen saturation of 90 percent or less should receive supplemental oxygen. Additional respiratory support should be provided as dictated by the patient's clinical condition. Hydration status should be assessed and supplemental fluid administered if needed. In patients requiring hospital admission for suspected bacterial pneumonia, intravenous antibiotics should be administered in the emergency department. Empiric coverage should be guided by the age of the patient and the epidemiologic data discussed above. T§ble.,..1.,.1..9.-.3 contains suggested inpatient and outpatient antibiotic therapy. In newborns, ampicillin (150 to 300 mg/kg/day) in combination with either an aminoglycoside (gentamicin 2.5 mg/kg per dose) or a third-generation cephalosporin (cefotaxime 100 to 150 mg/kg/day) is preferred. The ampicillin provides coverage against Listeria and enterococcal species. For infants with pneumonitis syndrome or afebrile pneumonia (see above), erythromycin (40 mg/kg/day qid) is the drug of choice. In children 3 months to 5 years of age, ampicillin (150 mg/kg/day qid) or cefuroxime (150 mg/kg/day tid) alone is usually sufficient. In children who are unresponsive to this therapy or who have a suggestive clinical presentation, mycoplasma and chlamydial infections should be considered. Appropriate coverage for these infections include erythromycin (40 mg/kg/day qid) or clarithromycin (15 mg/kg/day bid). In children over 5 years of age, erythromycin or clarithromycin alone is usually sufficient. In severely ill hospitalized children in this age group, the addition of cefuroxime should be considered. In all age groups, if resistant S. pneumoniae is suspected, vancomycin should be added.36

TABLE 119-3 Antibiotic Therapy for Children with Pneumonia

Children with fulminant viral pneumonia, such as an immunocompromised patient with varicella, may require treatment with acyclovir. In RSV pneumonia, ribavirin therapy should be considered for selected high-risk children, such as those with significant underlying cardiopulmonary or oncologic diseases and those with severe RSV pneumonia. Lymphocytic interstitial pneumonia in HIV-positive children should include a combination of prednisone and zidovudine. Bone marrow and solid organ transplant patients with cytomegalovirus pneumonia may require ganciclovir and gammaglobulin. In a recent study, ceftazidime or ceftriaxone eradicated nosocomial pneumonia in 90 percent of cases, but ceftazidime had improved efficacy against Pseudomonas aeruginosa. Children with cystic fibrosis often develop acute infectious exacerbations secondary to Pseudomonas and S. aureus, often with reduced antimicrobial resistance to standard antibiotics.

Most children with uncomplicated pneumonia can be treated as outpatients. If a bacterial cause is suspected, the patient should be placed on an appropriate antibiotic. The choice of oral antibiotic should be based on the considerations discussed above regarding the most likely etiologic organisms based on the age and clinical presentation of the patient. For outpatient treatment, amoxicillin (40 mg/kg/day tid) is preferred for children between 3 months and 5 years. 36 Alternatively, daily intramuscular ceftriaxone may be used.3 38 After 5 years of age and in penicillin-allergic children, erythromycin (40 mg/kg/day qid) or tetracycline (in children >9 years of age) are the preferred initial agents. Recent data indicate similar cure rates, fewer side effects, and reduced termination of therapy with clarithromycin compared to erythromycin.3940 Azithromycin has also been shown to have a cure rate equal to that of erythromycin in children with community-acquired pneumonia. 41 It should be noted that both of these drugs are significantly more expensive than erythromycin or tetracycline.

If viral pneumonia is suspected, no specific antibiotic therapy is warranted. Symptomatic treatment should include fever control and hydration. Patients with viral pneumonia often have a mixture of airway and air-space disease. If the patient has prominent airway disease (bronchiolitis-like) symptoms, bronchodilator therapy should be considered.

All patients discharged with a diagnosis of pneumonia should have routine follow-up with a primary care provider within 1 to 2 days. The duration of therapy varies with the clinical response, predisposing host factors, and suppurative complications. Ten days of antimicrobial treatment should suffice for most uncomplicated cases.

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