This case discusses a 1 year and 6 month old female child who presented with cough, fever and hurried respiration for 5 days and was admitted to the hospital with a provisional diagnosis of severe pneumonia with right side empyema thoracis and anemia. Over the course of 16 days in the hospital, the child was treated with antibiotics, bronchodilators, steroids and blood transfusions. Laboratory tests showed improvement in hemoglobin levels but persistent consolidation in the lungs. The child was discharged on oral iron supplements and referred to another hospital for further management.

1. An Approach To A Case
Of Pneumonia With Iron
Deficiency Anemia
Presented By:-
Mili Bulsari : 182540888020
Kairvi Raval: 182540888021
Doctor Of Pharmacy Year 3,

2. TABLE OF CONTENTS:
PATIENT COUNSELLING
05
● ABOUT THE DISEASE
● ABOUT THE MEDICATION
● LIFESTYLE MODIFICATION
PHARMACEUTICAL CARE
PLAN
04
● SUBJECTIVE EVIDENCE
● OBJECTIVE EVIDENCE
● ASSESSMENT
● PLAN
DAY NOTES
03
● PATIENT’S PHYSICAL EXAMINATION
AND VITAL SIGNS
● LABORATORY PARAMETERS
● MEDICATION CHART
PROVISIONAL DIAGNOSIS
02
PATIENT DEMOGRAPHICS
01
● PATIENT”S COMPLAINTS
● HISTORY
● PAST MEDICAL AND MEDICATION HISTORY

3. DISEASE OVERVIEW
PNEUMONIA
Pneumonia is an infection that
affects one or both the lungs.
It caused the air sacs or
alveoli of the lungs to fill with
the fluid or pus.
Figure shows pneumonia caused by bacteria.
Figure A shows pneumonia affecting part of left lung
Figure B shows healthy alveolar sac
Figure C shows alveolar sac filled with mucus

4. DISEASE OVERVIEW
ETIOLOGY
BACTERIA
Streptococcus Pneumoniae
Mycoplasma Pneumoniae
Legionella pneumophila
VIRUS
Influenza virus
Rhinovirus
Respiratory Syncytial Virus
FUNGI
Pneumocystis jirovecii

5. DISEASE OVERVIEW
COMPLICATIONS OF PNEUMONIA THAT MAY BE LIFE
THREATENING INCLUDES
ACUTE RESPIRATORY DISTRESS (ARDS) AND RESPIRATORY FAILURE
MAJOR ORGAN DAMAGE (KIDNEY, LIVER, HEART)
NECROTIZING PNEUMONIA
PLEURAL DISORDERS (EXAMPLE: EMPYEMA THORACIS)
SEPSIS

6. DISEASE OVERVIEW
EMPYEMA THORACIS
EMPYEMA THORACIS is defined as collection of pus in the pleural space.
Development of empyema is a progressive process in association with pneumonia
STAGE 1: EXUDATIVE PHASE
STAGE 2: FIBRINOPURULENT
PHASE
STAGE 3: ORGANIZING PHASE

7. DISEASE OVERVIEW
IRON DEFICIENCY ANEMIA
It is defined as decrease in total iron body content
Iron deficiency causes diminished erythropoiesis and can cause the
development of anemia

8. DEMOGRAPHIC DETAILS
EPIDEMIOLOGIC DATA
NAME XYZ ---
AGE 1 year 6 months old Children below 2 years old are
prone to develop pneumonia
The risk of development of
pneumonia is higher in premature
babies
GENDER Female ---
UNIT PAED-I ---

9. REASON FOR ADMISSION
C/O •Cough and fever since 5 days
•Hurried respiration since 1 day
PMHX h/o contact with TB patient
FAMILY HISTORY NKA
ALLERGIES NKA

10. PROVISIONAL
DIAGNOSIS
Severe pneumonia with right side
empyema thoracis with anemia?

11. DAY NOTES
DAY 1:
BP : 90/60
R.R 50/min
O/E : Fever with cough and
hurried respiration
Adv: CBC, CXR, ECG, BLOOD
TRANSFUSION

12. DAY 1 : HAEMATOLOGICAL AND
BIOCHEMICAL FINDINGS
PARAMETERS VALUE NORMAL RANGE
Haemoglobin 7.6 gm/dL 11.5-15.5 gm/dL
WBC 11000 cells/mm^3 4000-11000
cells/mm^3
DLC
N
E
B
L
M
25%
0.1%
00%
67%
04%
53-75%
1-6%
0-1%
20-50%
2-10%
Platelets 5.54 Lacs/mm^3 1.5-5 Lacs/mm^3
ELECTROLYTES
Na
K
Cl
133 mmol/lit
4.8 mmol/lit
105 mmol/lit
135-147 mmol/lit
3.5-5 mmol/lit
95-105 mmol/lit
BIOCHEMISTR
Y
VALUE NORMAL RANGE
Sr.Cr 0.9 mg/dL 0.8-1.4 mg/dL
UREA 40 mg/dL 11-36 mg/dL
LDH 250 U/L 110-295 U/L

13. DAY 1: MEDICATION CHART
DRUG DOSE ROUTE FREQ INDICATION
LINEZOLID 80mg IV 1-1-1 For treating
infection
AMIKACIN 60mg IV 1-0-1 For treating
bacterial infection
Supp.DIAZEPAM 170mg P.R. SOS As sedative
Neb.SALBUTAMOL 0.2ml/2.5ml NS P.N. Q2H Bronchodilation
HYDROCORTISONE 100 mg P.O. STAT For preventing
pulmonary and systemic
inflammation
Neb.ADRENALINE 3ml P.N. STAT For Improving Lung
function
FUROSEMIDE 10mg IV STAT For prevent respiratory
distress
PARACETAMOL DROPS 1ml P.O. SOS As antipyretic
METRONIDAZOLE
DROPS
80mg P.O. 1-1-1 For preventing further
infections
1 PINT OF BLOOD IV STAT For managing Hb levels

14. DAY NOTES
DAY 2:
Pulse :153/min
R.R- 44/min
O/E Fever with spikes++, distress+
Adv :CST

15. DAY 2 : HAEMATOLOGICAL AND
BIOCHEMICAL FINDINGS
PARAMETERS VALUE NORMAL RANGE
Haemoglobin 12.8g/dL 11.5-15.5 gm/dL
ELECTROLYTES
Na
K
Cl
134 mmol/lit
3.2 mmol/lit
99 mmol/lit
135-147 mmol/lit
3.5-5 mmol/lit
95-105 mmol/lit

16. DAY NOTES
DAY 3:
Pulse: 120/min
R.R: 42/min
O/E RT side air entry- better, B/L crepts+
CNS- NAD
Adv :CST

17. DAY NOTES
DAY 4:
Pulse: 118/min
R.R- 43/min
O/E Afebrile
RS: decreased breath sounds on RT side
P/A Distention+
Adv: CST

18. DAY NOTES
DAY 5:
Pulse: 120/min
R.R- 46/min
O/E air entry better on RT side, B/L crepts+
Decreased breath sounds on RT side
Adv: CST

19. DAY NOTES
DAY 6:
Pulse: 102/min
R.R- 48/min
O/E Afebrile
RS: air entry better on RT side, B/L crepts+
Adv: CST

20. DAY NOTES
DAY 7:
O/E GC- fair, afebrile, vitals stable, no resp.
distress
RS: air entry better on RT side, B/L crepts+
Adv: Ultrasound thorax

21. DAY NOTES
DAY 8:
Pulse: 130/min
O/E GC fair, afebrile, temp 99⁰F
RS: air entry better on RT side
P/A soft and tender, mild chest retraction
Tachypnea+
Adv: Spo2 monitoring, CST.

22. DAY NOTES
DAY 9:
Pulse- 104/min
O/E Afebrile, tachypnea decreased
P/A Soft
CNS- NAD
Adv: CST, CBC, Paed. Surgeon opinion

23. DAY 9 : HAEMATOLOGICAL AND
BIOCHEMICAL FINDINGS
PARAMETERS VALUE NORMAL RANGE
Haemoglobin 12.5 gm/dL 11.5-15.5 gm/dL
WBC 20800 cells/mm^3 4000-11000
cells/mm^3
DLC
N
E
B
L
M
61%
0.1%
00%
34%
04%
53-75%
1-6%
0-1%
20-50%
2-10%
Platelets 4.9 Lacs/mm^3 1.5-5 Lacs/mm^3
Bleeding time
Clotting time
ESR
2 mins 3 secs
6 mins 8 secs
50mm/hr

24. DAY NOTES
DAY 9:
CXR- Effusion on right side
Adv- ICD with LA
NBM from 6 am on 09/05/09
Shift to on call basis

25. DAY NOTES
DAY 10:
O/E Afebrile, vitals stable
RS- decreased breath sounds, B/L crepts+
CVS- stable
P/A- Soft
CNS- NAD

26. DAY NOTES
DAY 11:
Pulse: 122/min
O/E GC stable, decreased breath sounds
Adv: collect C/S report, RPT chest X-ray on 11/05/09
Paed. Surgeon opinion, physiotherapy

27. DAY NOTES
DAY 12:
O/E Afebrile, vitals stable
Rs-Air entry better on right side, B/L
crepts+
CVS: S1S2 normal no murmur
P/A- Soft and non-tender
CNS- NAD
Adv- CST

28. DAY NOTES
DAY 12: Chest X-Ray Report
CXR shows consolidation in both the lungs

29. DAY NOTES
DAY 13:
Pulse- 92/min
SPO2 98%
O/E- Afebrile
CVS- S1S2 normal, no murmur
Rs-B/l equal air entry, NVBS
P/A-Soft, non-tender
CNS- NAD
Adv- CST, ICD removal

30. DAY NOTES
DAY 14:
Pulse- 92/min
Spo2 98%
O/E- Afebrile
Rs- air entry better, B/L crepts+
CVS- S1 S2 normal, no murmur
CNS- NAD
Adv- CST

31. DAY NOTES
DAY 15:
Pulse- 94/min
O/E- Afebrile, vitals stable, Pallor+
Rs: B/L equal air entry, NVBS
Adv:CST, CBC

32. DAY 15 : HAEMATOLOGICAL AND
BIOCHEMICAL FINDINGS
PARAMETERS VALUE NORMAL RANGE
Haemoglobin 10.8 gm/dL 11.5-15.5 gm/dL
WBC 8700 cells/mm^3 4000-11000
cells/mm^3
DLC
N
E
B
L
M
58%
01%
00%
38%
03%
53-75%
1-6%
0-1%
20-50%
2-10%
Platelets 3.82 Lacs/mm^3 1.5-5 Lacs/mm^3

33. DAY NOTES
DAY 16:
Pulse- 120/min
O/E- Afebrile
Rs- B/L equal air entry, B/L crepts+
CVS: S1S2 normal, no murmur
P/A: Soft, non-tender
CNS: NAD
The child was referred to Indira gandhi institute of child health

34. PHARMACEUTICAL
CARE PLAN

35. SUBJECTIVE EVIDENCE
● Cough
● Fever
● tachypnoea
● Chest retraction
● Pallor

36. OBJECTIVE EVIDENCE
● CXR : Consolidation in both lungs, pleural effusion
● Rales sound
● Hb : Significantly low (7.6 gm/dL) on day 1 and (10.8 gm/dL) on day 15
● RBC count
● Sputum culture
● Ultrasound of thorax
● WBC count

37. ASSESSMENT
FINAL DIAGNOSIS
SEVERE PNEUMONIA WITH
IRON DEFICIENCY ANAEMIA

39. PLEURAL FLUID

40. EMPYEMA THORACIS
1 INFLAMMATION OF PULMONARY CAPILLARIES
CAUSES CAPILLARIES TO CONTRACT
2 CAUSES INCREASE IN VASCULAR PERMEABILITY
4 LEADING TO PLEURAL EFFUSION
PUS IN THE PLEURAL SPACE = EMPYEMA THORACIS
3 FLUID LEAK FROM VESSELS INTO THE PLEURAL
SPACE

41. IRON DEFICIENCY ANEMIA
HEPCIDIN
LIMITS REPLENISHING
IRON STORES
LIMITS ABSORPTION
OF IRON IN BLOOD
INCREASES
STORAGE OF IRON
IL-6
INFLAMMATION

42. PLAN
SHORT-TERM GOALS
● To assess severity of pneumonia
to determine appropriate initial
treatment setting
● To relieve symptoms such as
cough, shortness of breath, chest
pain, fever.
● To replenish iron stores
LONG-TERM GOALS
● To eradicate infecting pathogen
● Prevent morbidity and mortality
● Improve patient’s quality of life
● To ensure that there is an adequate
response to iron therapy and that iron
therapy is continued until after
correction of the anemia to replenish
body iron stores

43. TREATMENT OPTIONS
ORAL IRON PREPARATIONS
SALT ELEMENTAL IRON
FERROUS SULPHATE 20
FERROUS GLUCONATE 12
FERROUS FUMARATE 33
POLYSACCHARIDE IRON COMPLEX 100
CARBONYL IRON 100

44. TREATMENT OPTIONS
PARENTERAL IRON PREPARATIONS
SODIUM FERRIC GLUCONATE 62.5 mg iron/ 5ml
IRON DEXTRAN 50 mg iron/ ml
IRON SUCROSE 20 mg iron/ ml

45. TREATMENT OPTIONS
FOR PNEUMONIA
AMOXICILLIN 25-50 mg/kg BID
CEFTRIAXONE 50-75 mg/kg/day BID
PIPERICILLIN + TAZOBACTUM 50+6.25 mg/kg/day TID

46. MONITORING PARAMETERS
RENAL FUNCTION
HAEMOGLOBIN LEVELS
RESPIRATORY RATES
CXR

47. PREDICAMENTS AND POINTS TO PHYSICIAN
● MCV and MCH values not mentioned
● Cultural sensitivity reports were not provided
● Blood culture test was not carried out
● Arterial blood gas test was not underdone
● C- Reactive protein test was not underdone
● According to revised WHO treatment guidelines for pneumonia, children aged 2 months to 1
year having severe pneumonia should be prescribed with
● AMPICILLIN 50 mg/kg IM/IV every six hourly for 5 days
● GENTAMICIN 7.5 mg/kg IM/IV for 5 days = This is the 1st line of treatment for severe
pneumonia in pediatric patient which was not followed
● CEFTRIAXONE should be the 2nd line of choice for the same
● Cough suppressing agents were not prescribed

48. PATIENT COUNSELLING
ABOUT THE DISEASE
Your child has pneumonia, which is an
infection of lungs after getting back
home, your child will probably still have
symptoms.
● Coughing will slowly get better over
7-14 days
● Sleeping and eating patterns will
take a week to get back to normal
ABOUT THE MEDICATION
Your child will be administering
antibiotics which will help your child to
get better
● DO NOT miss any doses
● It is okay to use PARACETAMOL
for fever and pain
● Even if your child feels better with
the symptoms make sure to
complete the course which is
prescribed

49. PATIENT COUNSELLING
HOME CARE REMEDIES:
● Breathing warm moist air loosens the sticky mucus that may choke your child, this include
● Placing a warm wet washcloth loosely near to your child’s nose or mouth
● Filling a humidifier with warm water and having your child breathe the warm mist
● DO NOT use steam vaporizers as they cause burns
● To bring up the mucus from lungs, tap your child’s chest gently. This can be done when your child is
laying down
● Try to keep other children away from your child to prevent spreading of infection
● DO NOT allow anyone SMOKE anywhere near your child
● Make sure your child drink more fluids:
● Offer whole milk
● Offer a tea containing fennel, cardamom, ginger, sugar and mint
● Offer warm drinks consisting sugar, honey, lemon juice,basil leaves, mint, ginger,This will help to relax
the airway and loosen the mucus
● In case your child throws out the food due to coughing, wait 10-15 minutes and try to feed again

50. PATIENT COUNSELLING
CONSULT THE PHYSICIAN WHEN:
● Your child experience difficulty in breathing (by observing the breathing pattern = hurried
respiration)
● Making a grunting noise
● When colour of the skin, nails, area beneath eyes, gums or lips turn blue or bluish grey in
colour
● Has trouble sleeping
● When your child experience tiredness and fatigued
● When your child experience difficulty in walking
● Inadequate Urination

51. PREVALENCE OF PNEUMONIA IN INDIA
● After Tuberculosis, Pneumonia is the second most prominently
occuring disease worldwide. India itself accounts for 36% of the
global pneumonia burden.
● Which means 194 over 10,000 people are pneumonic in that 15%
mortality rate has been accounted in children under the age of 5
● in year 2017,Pneumonia killed 8,08,694 children under the age of 5

52. EMERGENCE OF MULTIDRUG RESISTANT S.
PNEUMONIAE WORLDWIDE
● Since the introduction of antimicrobial drugs therapy, S.pneumoniae
has shown strong ability to acquire resistance
● National Institute of Health suggest that, resistance towards
macrolides in s. pneumoniae are high and still rising
● This is because of the recent mutations in the 23S rRna genes in
L22 and L4 ribosomal proteins
● Similarly resistance towards fluoroquinolones was also observed
which is emerging on very high rates
● It also observed developing resistance towards Tetracycline

53. RECENT ADVANCES IN ANTIBIOTIC THERAPY FOR
PNEUMONIA
CEFDITOREN
● 3rd Generation oral cephalosporin
● According to pooled analysis of the clinical trials carried out by Dr Juan Jose, PhD Scholar
Maria Jose Granizo, PhD scholar Lorenzo Aguilar, cefditoren shows high efficacy
approximately 90% against streptococcus pneumoniae (including penicillin intermediate and
penicillin resistant strains) and showing 85% efficacy against H.influenzae

54. RECENT ADVANCES IN ANTIBIOTIC THERAPY FOR
PNEUMONIA
SOLITHROMYCIN
● A novel fluoro ketolide which is formulated in both oral and parenteral routes to overcome the
macrolide resistant pathogen causing bacterial pneumonia
● In phase II/III Clinical trials at 800 mg OD Loading dose on day 1 and 400 mg OD maintenance
dose on day 2-5 is proven effective
ZABOFLOXACIN
● A novel fluoroquinolone that has potent activity against gram positive pathogens
● Recent studies showed that zabofloxacin shows potent activity against invasive and non
invasive streptococcus pneumoniae.
● This drug targets DNA gyrase and Topoisomerase IV

55. PREVENTION OF PNEUMONIA
● Immunization against Hib, Pneumococcus, measles
Example: PCV13, PCV7, PPSV23
● Adequate nutrition is key to improve children’s natural defences, starting with exclusive
breastfeeding for the first 6 months of life
● Encourage good hygiene
● Smoking cessation

56. REFERENCES:
● A V Budnevsky, E Esaulenko, A V Chernov, E V Voronina , Article of ANAEMIC SYNDROME IN PATIENTS
WITH COMMUNITY ACQUIRED PNEUMONIA, National library of medicine, National center of biotechnology
information, 2016
● Alexander K C Leung, Alex H C Wong, Kam L Hon, Article of community acquired pneumonia in children,
Recent patents on inflammation and allergy drug discovery, 11/09/2018 Page 133-144
● Varon E, Mainardi J L, Gutmann L, Streptococcus: still a major pathogen, clinical microbiology 2010
● Ferrera, AM, new fluoroquinolones in lower respiratory tract infections and emerging patterns of pneumococcal
resistance infection 2005 page 106-114
● Park H.S, Jung S.J, Kwak J.H, DNA gyrase and topoisomerase IV and the dual targets of zabofloxacin in
streptococcus pneumoniae, International journal of antimicrobial agents 2010- page 97-98

57. THANKYOU!