The main treatment for pneumonia is antibiotics, along with rest and drinking plenty of water. If you have chest pain, you can take pain killers such as paracetamol. Treatment depends on how severe your pneumonia is. Treatment with antibiotics should be started as soon as possible after diagnosis.

1. Management of Pneumonia
Sumi Singh
Nepal Medical College and Teaching Hospital

2. Investigation
• Complete Blood Count : Leukocytocis
• C-Reactive Protein
• Arterial Blood Gas Analysis
• Renal function test (Urea >7 mmol/L and Hyponatremia indicates
severity)
• Liver Function Test

3. • Blood Culture & Sensitivity
• Sputum Examination : Gram Staining and Culture
• Pleural fluid : Gram staining and culture
• ELISA during the acute stage : IgM antibody (in atypical pneumonia)
• Complement fixation test after one week of illness : IgG antibodies
• Polymerase Chain Reaction (PCR)

4. • Chest X – ray :
• Hyperinflation & Interstitial infiltrates (Viral Pneumonia)
• Consolidation
• Pneumatoceles (Staphylococcal & Klebsiella)
• Blunt Costo-Phrenic angles (Pleural Effusion,Empyema,
pyopneumothorax(Staphylococcus))

7. Definitive diagnosis of a viral infection
• Isolation of a virus in respiratory tract secretions by culture
• Growth of respiratory viruses in conventional viral culture usually
requires 5-10 days, although shell vial cultures can reduce this “
turnaround time ” to 2-3 days.
• Detection of the viral genome or antigen in respiratory tract
secretions by PCR

8. Other investigation for Viral Pneumonia
• Reliable DNA or RNA tests for the rapid detection of RSV,
parainfluenza, influenza, and adenoviruses are available and accurate.
• Serologic testing may be valuable as an epidemiologic tool

9. Definitive diagnosis of a bacterial infection
• Isolation of an organism from the blood, pleural fluid, or sputum.
• Blood culture results are positive in only 10% of children with
pneumococcal pneumonia.

10. Diagnosis of Mycoplasma pneumonia infection
• Acute infection caused by M. pneumoniae can be diagnosed on the
basis of a positive polymerase chain reaction (PCR) test result.
• Seroconversion in an IgG assay

11. • Cold agglutinins at titers > 1 : 64 are found in the blood in ≈ 50% of
patients with M. pneumoniae infections

13. Treatment

15. • Treatment of suspected bacterial pneumonia is based on the
presumptive cause and the age and clinical appearance of the child.
• For mildly ill children who do not require hospitalization, amoxicillin is
recommended (25 – 50 mg/kg/day)
• In communities with a high percentage of penicillin-resistant
pneumococci, high doses of amoxicillin (80-90 mg/kg/24 hr) should
be prescribed.
• Therapeutic alternatives include cefuroxime (75 – 150 mg/kg/day)and
amoxicillin/clavulanate (40 – 60 mg/kg/day)

16. Suspected M.pneumoniae or C. pneumoniae
• School going children : A macrolide antibiotic such as azithromycin is
an appropriate choice
• In adolescents, a respiratory fluoroquinolone (levofloxacin,
moxifloxacin, gemifloxacin) may be considered as an alternative

17. If viral pneumonia is suspected
• Withhold antibiotic therapy, especially for those patients who are
mildly ill, clinical evidence suggesting viral infection, and are in no
respiratory distress.
• Deterioration in clinical status should signal the possibility of
superimposed bacterial infection, and antibiotic therapy should be
initiated

19. In – Hospital Management
• Nil Per Oral
• O2 supplementation
• Nebulization
• Antipyretics for fever
• Intravenous fluids
• Anti – microbial therapy

22. • Parenteral cefotaxime or ceftriaxone is the mainstay of therapy when
bacterial pneumonia is suggested.
• If clinical features suggest staphylococcal pneumonia (pneumatoceles,
empyema), initial antimicrobial therapy should also include
vancomycin or clindamycin.

24. Duration of therapy
• Antibiotics should probably be continued until the patient has been
afebrile for 72 hours, and the total duration should not be less than
10 to 14 days (or 5 days if azithromycin is used).
• oral zinc (20 mg/day) helps accelerate recovery from severe
pneumonia.

25. MANAGING COMPLICATIONS

26. • Complications of pneumonia are usually the result of direct spread of
bacterial infection within the thoracic cavity (pleural effusion,
empyema, pericarditis) or bacteremia and hematologic spread
• Meningitis, suppurative arthritis, and osteomyelitis are rare
complications of hematologic spread of pneumococcal or H.
influenzae type b infection.

28. • S. aureus, S. pneumoniae, and S. pyogenes are the most common
causes of parapneumonic effusions and of empyema
• The treatment of empyema is based on the stage (exudative,
fibrinopurulent, organizing).
• Imaging studies including ultrasonography and CT are helpful in
determining the stage of empyema.
• The mainstays of therapy include antibiotic therapy and drainage with
tube thoracostomy.

30. • Additional approaches include the use of intrapleural fibrinolytic
therapy (urokinase,streptokinase, tissue plasminogen activator) and
selected videoassisted thoracoscopy (VATS) to debride or lyse
adhesions, and drain loculated areas of pus.
• Late Stage requires thoracotomy and open debridement.

31. • Intercostal Chest tube drainage under water seal for large effusions
causing respiratory distress
• Mechanical Ventilation for Impending Respiratory Failure

32. PROGNOSIS

33. • Patients with uncomplicated community-acquired bacterial
pneumonia show response to therapy, with improvement in clinical
symptoms (fever, cough, tachypnea, chest pain), within 48-96 hr of
initiation of antibiotics

34. A number of factors must be considered when a patient does not
improve with appropriate antibiotic therapy:
(1) complications, such as empyema;
(2) bacterial resistance;
(3) nonbacterial etiologies such as viruses and aspiration of foreign
bodies or food;
(4) bronchial obstruction from endobronchial lesions, foreign body, or
mucous plugs;

35. (5) pre-existing diseases such as immunodeficiencies, ciliary dyskinesia,
cystic fibrosis, pulmonary sequestration, or cystic adenomatoid
malformation; and
(6) other noninfectious causes (including bronchiolitis obliterans,
hypersensitivity pneumonitis, eosinophilic pneumonia, aspiration, and
Wegener’s granulomatosis).

36. • A repeat chest radiograph is the 1st step in determining the reason
for delay in response to treatment

37. Mortality
• Pneumonia is the single largest cause of death in children worldwide.
Every year, it kills an estimated 1.4 million children under the age of
five years, accounting for 18% of all deaths of children under five
years old worldwide

38. Protecting children from pneumonia include
• promoting exclusive breastfeeding and hand washing, and reducing
indoor air pollution;
• prevent pneumonia with vaccinations;
• treat pneumonia are focused on making sure that every sick child has
access to the right kind of care - either from a community-based
health worker, or in a health facility if the disease is severe - and can
get the antibiotics and oxygen they need to get well.

39. PREVENTION
• Universal childhood vaccination with conjugate vaccines for H.
influenzae type b and S. pneumonia
• Annual influenza vaccine is recommended for all children over 6
months of age
• Trivalent, inactivated influenza vaccine is licensed for use beginning at
6 months of age; live, attenuated vaccine can be used for persons 2 to
49 years of age

40. Prevention of Hospital Acquired Pneumonia
• Reducing the duration of mechanical ventilation and administering
antibiotics judiciously reduces the incidence of ventilator-associated
pneumonias
• The head of the bed should be raised to 30 to 45 degrees for
intubated patients to minimize risk of aspiration, and all suctioning
equipment and saline should be sterile.
• Hand washing before and afterevery patient contact and use of gloves
for invasive procedures are important measures to prevent
nosocomial transmission of infections.

41. References
• Nelson Textbook of Pediatrics – 19th Edition
• Nelson Essential Pediatrics – 7th Edition
• Ghai Essential Pediatrics – 8th Edition
• Management of Pediatric Community-acquired Bacterial Pneumonia-
AAP Publications