What is the best next step in managing a 12-year-old girl with Streptococcus pneumoniae (S. pneumoniae) pneumonia, who remains febrile with tachycardia, tachypnea, and localized dullness to percussion, despite intravenous ampicillin therapy?

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Last updated: May 11, 2025 • View editorial policy

From the Guidelines

The best next step in management for this 12-year-old girl with pneumonia is to repeat the chest x-ray (option D). Despite 48 hours of appropriate antibiotic therapy with ampicillin for confirmed Streptococcus pneumoniae pneumonia, the patient continues to have significant fever, tachypnea, and diminished breath sounds at the right lung base. These findings suggest a possible complication such as a parapneumonic effusion or empyema that may require additional intervention. The dullness to percussion at the right base further supports this concern. Repeating the chest x-ray would help identify if there is fluid accumulation or worsening consolidation that might explain her lack of clinical improvement, as recommended by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America 1. If an effusion is identified, further evaluation with chest ultrasound or CT scan might be needed, potentially followed by thoracentesis or chest tube placement if a significant effusion or empyema is present. Adding azithromycin is unnecessary since the pathogen is already identified and sensitive to the current antibiotic. Procalcitonin levels, immunoglobulin testing, and repeat sputum cultures would not address the immediate concern of a possible complication requiring intervention.

Key points to consider in this case include:

  • The patient's lack of clinical improvement despite appropriate antibiotic therapy
  • The presence of dullness to percussion and diminished breath sounds at the right lung base, suggesting a possible complication
  • The need for further evaluation with imaging studies, such as chest x-ray, ultrasound, or CT scan, to identify any complications
  • The potential need for additional intervention, such as thoracentesis or chest tube placement, if a significant effusion or empyema is present, as outlined in the guidelines for the management of community-acquired pneumonia in infants and children older than 3 months of age 2, 3.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Management

The patient is a 12-year-old girl with pneumonia, currently being treated with intravenous ampicillin. The sputum culture has grown Streptococcus pneumoniae, which is sensitive to ampicillin and ceftriaxone.

  • The patient's current symptoms, such as dullness to percussion and diminished breath sounds at the right lung base, suggest the presence of a pleural effusion.
  • The best next step in management would be to investigate the cause of the pleural effusion, as the treatment and prognosis largely depend on its cause 4.

Diagnostic Approach

  • A pleural effusion can be diagnosed using thoracocentesis, which involves puncturing the pleural space to obtain a sample of the fluid for analysis 5, 4.
  • Laboratory testing, including chemical and microbiological studies, as well as cytological analysis, can help distinguish between a transudate and an exudate, and provide further information about the etiology of the disease process 5.
  • Imaging studies, such as a chest x-ray, can also be used to evaluate the size and location of the pleural effusion.

Treatment Options

  • The treatment of pleural effusion depends on the underlying cause, and may include antibiotics, pleural drainage, and other interventions 6, 4.
  • In cases of parapneumonic pleural effusion, the management may involve selecting an antibiotic regimen according to the origin of the pleural infection, and considering pleural drainage and other therapies as needed 6.
  • The patient is already being treated with ampicillin, which is effective against Streptococcus pneumoniae, and the addition of other antibiotics may not be necessary at this time.

Next Steps

  • Considering the patient's symptoms and the presence of a pleural effusion, the best next step would be to: + Repeat the chest x-ray to evaluate the size and location of the pleural effusion (option D).
  • This will help guide further management and determine the need for additional interventions, such as pleural drainage or other therapies.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.