What is the best course of action for a 9-month-old male patient with bronchopneumonia, severe respiratory infection, dehydration, and worsening symptoms despite treatment with co-amoxiclav (amoxicillin-clavulanate), paracetamol (acetaminophen), and salbutamol (albuterol)?

Admission Orders for 9-Month-Old with Severe Bronchopneumonia and Treatment Failure

This infant requires immediate hospital admission with intravenous antibiotic therapy due to multiple high-risk features: vomiting preventing oral medication absorption, poor feeding/hydration, tachypnea (RR 58), tachycardia (PR 200), fever, young age, and failure of outpatient oral co-amoxiclav therapy. 1

Admission Status and Location

• Admit to general pediatric ward with continuous cardiorespiratory monitoring 2
• Consider ICU consultation if requiring FiO2 ≥0.50 to maintain SpO2 >92% or signs of impending respiratory failure develop 3, 2

Vital Signs and Monitoring

• Vital signs every 4 hours: temperature, respiratory rate, heart rate, oxygen saturation 2
• Continuous pulse oximetry monitoring 1, 3
• Strict intake/output monitoring with daily weights 2
• Assess for signs of deterioration: increased work of breathing, apnea, grunting, altered mental status 4

Oxygen Therapy

• Maintain SpO2 >92% at all times 1, 2
• Currently SpO2 97% on room air, continue monitoring
• Initiate supplemental oxygen via nasal cannula if SpO2 drops <92% 1, 3
• Escalate to ICU if requiring FiO2 ≥0.50 to maintain adequate saturation 3, 2

Intravenous Antibiotic Therapy

Switch to IV antibiotics immediately due to vomiting and treatment failure on oral co-amoxiclav 1

Primary Regimen:

• Ampicillin-sulbactam IV (or IV co-amoxiclav if available): 150 mg/kg/day of ampicillin component divided every 6 hours 2
  • For 8.4 kg infant: approximately 315 mg ampicillin component per dose IV every 6 hours
• PLUS Azithromycin IV: 10 mg/kg once daily for first dose, then 5 mg/kg daily 2
  • For 8.4 kg infant: 84 mg IV day 1, then 42 mg IV daily
  • This covers atypical organisms (Mycoplasma, Chlamydia) given persistent lymphocytosis and treatment failure 1, 2

Alternative if above unavailable:

• Cefuroxime IV: 75-150 mg/kg/day divided every 8 hours 1
• OR Cefotaxime IV: 150-200 mg/kg/day divided every 6-8 hours 1

Rationale for IV therapy:

The British Thoracic Society explicitly states IV antibiotics are indicated when the child is unable to absorb oral antibiotics due to vomiting or presents with severe signs 1. This infant has both criteria: vomiting (×5 last night, ×2 today) and severe presentation (tachypnea RR 58, tachycardia PR 200, poor feeding, decreased activity) 1

Fluid Management

• IV fluids at 80% of maintenance to prevent SIADH 1, 2
  • Maintenance for 8.4 kg = 100 mL/kg/day × 8.4 = 840 mL/day
  • Give 80% = 672 mL/day (28 mL/hour) of D5 0.45% NaCl
• Monitor serum electrolytes daily 1, 2
• Avoid nasogastric tubes if possible as they compromise breathing in infants with small nasal passages 1

Fever Management

• Paracetamol (acetaminophen): 15 mg/kg/dose PO/IV every 4-6 hours as needed for fever >38.5°C or discomfort 1, 2
  • For 8.4 kg infant: 126 mg per dose (maximum 5 doses/24 hours)

Respiratory Support

• Elevate head of bed 30-45 degrees 2
• Gentle nasal suctioning as needed 2
• Do NOT order chest physiotherapy - it is not beneficial and should not be performed 1, 2
• Continue salbutamol nebulization only if wheezing present (not routinely indicated for pneumonia alone) 1

Laboratory and Diagnostic Studies

• Blood culture before starting IV antibiotics 3, 2
• Complete blood count with differential (already elevated WBC with lymphocytosis - monitor trend) 1
• Serum electrolytes, BUN, creatinine (baseline and daily monitoring) 1, 2
• Blood gas if respiratory distress worsens 1
• Consider viral respiratory panel (RSV, influenza, etc.) to guide management 3, 4

Nutrition

• NPO initially given vomiting, then advance to small frequent feeds as tolerated 1, 2
• Monitor ability to maintain adequate oral intake as discharge criterion 2

Duration and Transition Plan

• Minimum 3 days IV antibiotics, then transition to oral if clinically improved 2
• Total antibiotic duration: 7-10 days 2
• Transition to oral co-amoxiclav (90 mg/kg/day divided BID) PLUS oral azithromycin when:
  • Afebrile ≥24 hours
  • Tolerating oral intake without vomiting
  • Improved work of breathing
  • Stable vital signs 1, 2

Re-evaluation Criteria

Re-evaluate at 48 hours if no improvement - consider complications such as empyema, lung abscess, or resistant organisms 1

Critical Pitfalls to Avoid

• Young age (9 months) is a major risk factor for severe disease and respiratory failure - this infant requires aggressive treatment and close monitoring 1, 3, 4
• Persistent lymphocytosis with treatment failure suggests possible atypical pathogen (Mycoplasma, Chlamydia) or viral co-infection requiring macrolide coverage 1, 2
• Tachycardia (PR 200) in context of fever and dehydration requires careful fluid management and monitoring for sepsis 1
• Do not rely on oral antibiotics when vomiting is present - this guarantees treatment failure 1

Discharge Criteria (for future reference)

• Afebrile ≥24 hours 2
• SpO2 >92% on room air 2
• Respiratory rate normalized for age 2
• Decreased work of breathing with resolution of retractions 3, 2
• Tolerating adequate oral intake 2
• Reliable follow-up arranged within 48-72 hours 1