What are the treatment and management recommendations for a child diagnosed with Community-Acquired Pneumonia (PCAP) with symptoms of fever, cough, and respiratory distress?

SOAP Note and Admitting Orders for 4-Year-Old with Community-Acquired Pneumonia

SUBJECTIVE

• Chief Complaint: 3-day history of cough, 1-day history of fever
• History of Present Illness: 4-year-old male (16.4 kg) presenting with progressive cough over 3 days, fever (38.5°C) for 1 day, poor feeding, reduced activity, and tachypnea. No vomiting reported.
• Review of Systems: Positive for fever, cough, decreased oral intake, lethargy. Negative for vomiting.

OBJECTIVE

• Vital Signs:

  • Temperature: 38.5°C
  • Respiratory Rate: 44 breaths/min (normal for age: 20-30)
  • Heart Rate: 166 bpm (tachycardia; normal for age: 80-120)
  • Weight: 16.4 kg
  • Oxygen Saturation: Must be obtained immediately 1

• Physical Examination:

  • General: Reduced activity level, poor feeding
  • Respiratory: Tachypnea (RR 44), rhonchi in left lower lung field
  • Cardiovascular: Tachycardia (HR 166)
  • Document presence/absence of: Retractions, nasal flaring, grunting, cyanosis, work of breathing 1

ASSESSMENT

Primary Diagnosis: Community-Acquired Pneumonia (CAP), moderate severity

Severity Assessment: This child meets criteria for hospitalization based on tachypnea (RR >50 breaths/min threshold for older children, significantly elevated for age 4), sustained tachycardia, poor feeding, and reduced activity 1. Immediate oxygen saturation measurement is critical to determine appropriate level of care 1.

PLAN

Admission Orders

1. ADMISSION LOCATION 1

Admit to general pediatric ward with continuous cardiorespiratory monitoring capabilities given sustained tachycardia and tachypnea 1.

Escalate to ICU if any of the following develop:

• Oxygen saturation ≤92% despite FiO2 ≥0.50 1
• Impending respiratory failure (grunting, severe retractions, exhaustion) 1
• Altered mental status 1
• Need for noninvasive positive pressure ventilation 1
• Hemodynamic instability requiring vasopressor support 1

2. MONITORING 1, 2

• Continuous pulse oximetry
• Vital signs (HR, RR, temperature, BP, SpO2) every 4 hours minimum 2
• Strict intake/output monitoring
• Daily weight
• Respiratory assessment every 4 hours (work of breathing, retractions, grunting, mental status)

3. OXYGEN THERAPY 1, 2

Maintain oxygen saturation >92% at all times 1, 2

• If SpO2 <92% on room air: Initiate supplemental oxygen via nasal cannula (start at 1-2 L/min) or face mask 1, 2
• Titrate to maintain SpO2 >92% 1, 2
• If requiring FiO2 ≥0.50 to maintain SpO2 >92%, transfer to ICU 1

4. ANTIBIOTIC THERAPY 2, 3, 4

First-Line Treatment: Ampicillin-Sulbactam (or Amoxicillin-Clavulanate if oral tolerated) PLUS Azithromycin

This 4-year-old requires hospitalization and has moderate severity CAP with tachycardia and tachypnea, warranting combination therapy to cover both typical bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae) and atypical organisms (Mycoplasma pneumoniae) 2, 3.

Specific Orders:

• Ampicillin-Sulbactam 150 mg/kg/day IV divided every 6 hours (based on ampicillin component)
  • For 16.4 kg patient: 615 mg IV every 6 hours
  • Alternative if oral intake adequate: Amoxicillin-Clavulanate 90 mg/kg/day PO divided BID 2

PLUS

• Azithromycin 10 mg/kg IV/PO once daily for Day 1, then 5 mg/kg/day Days 2-5 2, 5
  • For 16.4 kg patient: 164 mg (round to 160 mg) Day 1, then 82 mg (round to 80 mg) Days 2-5
  • Can use oral suspension if tolerating PO: 8 mL of 200 mg/5 mL suspension Day 1, then 4 mL Days 2-5 5

Duration: Minimum 3 days IV therapy, then transition to oral when clinically improved (afebrile >24 hours, improved work of breathing, tolerating PO) 3. Total antibiotic course: 5-7 days 2.

5. FLUID MANAGEMENT 1, 2

Intravenous fluids at 80% of maintenance given poor oral intake and risk of SIADH with pneumonia 1, 2

• Maintenance calculation: 100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg = 1000 + 320 = 1320 mL/24 hours
• Order: D5 0.45% NaCl at 44 mL/hour (80% of 1320 mL = 1056 mL/24 hours) 1
• Monitor serum electrolytes (sodium, potassium, chloride, bicarbonate) daily 1, 2
• Advance to oral fluids as tolerated; discontinue IV when taking adequate PO

Avoid nasogastric tube unless absolutely necessary as it may compromise breathing 2

6. SUPPORTIVE CARE 2

• Antipyretics: Acetaminophen 15 mg/kg PO/PR every 4-6 hours PRN fever (max 75 mg/kg/day)
  • For 16.4 kg: 246 mg (round to 240 mg) per dose
  • Alternative: Ibuprofen 10 mg/kg PO every 6 hours PRN fever
• Gentle nasal suctioning PRN if nasal congestion present 1
• NO chest physiotherapy - not beneficial and should not be performed 2
• Elevate head of bed 30-45 degrees
• Encourage oral intake when able

7. DIAGNOSTIC STUDIES 1

Blood Work:

• Complete blood count with differential
• Basic metabolic panel (sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose)
• Blood culture x2 (before antibiotics if possible) 1
• C-reactive protein or procalcitonin (optional, not required for management)

Imaging:

• Chest X-ray (PA and lateral if able, or AP if not) - likely already obtained for diagnosis
• Repeat CXR only if clinical deterioration or failure to improve after 48-72 hours 2

Microbiologic Testing:

• Nasopharyngeal swab for respiratory viral panel (including influenza, RSV, COVID-19) 3
• Consider Mycoplasma pneumoniae PCR if available (given age and atypical coverage initiated) 2

8. DIET

• NPO initially if significant respiratory distress
• Advance to clear liquids, then regular diet as tolerated
• Goal: Resume age-appropriate diet within 24-48 hours

9. ACTIVITY

• Bedrest with bathroom privileges
• Advance activity as tolerated based on respiratory status

10. DISCHARGE CRITERIA 6

Patient may be discharged when ALL of the following are met:

• Afebrile for ≥24 hours without antipyretics 2
• Oxygen saturation >92% on room air for ≥24 hours 6
• Respiratory rate normalized for age (<30 breaths/min) 6
• Decreased work of breathing with resolution of retractions 6
• Tolerating oral intake (fluids and medications) 6
• Improved activity level and appetite 6
• Reliable caregiver able to monitor at home 1

11. FOLLOW-UP 2

• Re-evaluate within 48 hours if not improving (persistent fever, worsening respiratory status, inability to tolerate PO) 2
• Outpatient follow-up with primary care provider in 3-5 days post-discharge
• Return precautions: Increased work of breathing, inability to drink, worsening symptoms, fever recurrence after initial improvement 2

Critical Pitfalls to Avoid

1. Delayed Oxygen Assessment: Oxygen saturation MUST be measured immediately on presentation - this single value determines appropriate level of care (ward vs. ICU) 1. Hypoxemia is the most critical indicator for escalation of care.

2. Inadequate Atypical Coverage: At age 4 years, Mycoplasma pneumoniae becomes increasingly prevalent as a cause of CAP 2. Macrolide coverage (azithromycin) is essential and should not be omitted 2, 3.

3. Fluid Overload: Pneumonia increases risk of SIADH. Always use 80% maintenance fluids and monitor electrolytes daily 1, 2. Avoid excessive fluid administration.

4. Missed Clinical Deterioration: Grunting is a sign of severe disease and impending respiratory failure 1. Sustained tachycardia (HR 166 in this patient) indicates significant physiologic stress and warrants continuous monitoring 1.

5. Inappropriate Discharge: Do not discharge until patient meets ALL discharge criteria, particularly sustained oxygen saturation >92% on room air 6. Premature discharge increases risk of readmission and complications.

6. Antibiotic Duration Error: Minimum 3 days of therapy required before considering transition to oral antibiotics 3. Total course should be 5-7 days 2.