What are the admitting orders for a 7-year-old patient with Community-Acquired Pneumonia (CAP)?

Admitting Orders for 7-Year-Old with Community-Acquired Pneumonia

Admit this 7-year-old patient to the pediatric ward with continuous pulse oximetry monitoring, initiate IV ampicillin 200 mg/kg/day divided every 6 hours plus azithromycin 10 mg/kg on day 1 then 5 mg/kg daily for days 2-5, provide supplemental oxygen to maintain SpO2 >92%, and administer IV fluids at 80% of maintenance rate. 1, 2

Admission Location and Monitoring

• Admit to pediatric ward with continuous pulse oximetry monitoring for standard CAP cases 2
• Transfer to ICU or step-down unit if any of the following are present 3:
  • SpO2 ≤92% on FiO2 ≥0.50 3
  • Signs of impending respiratory failure (grunting, recurrent apnea, severe retractions) 3
  • Sustained tachycardia or hemodynamic instability requiring pharmacologic support 3
  • Altered mental status from hypercarbia or hypoxemia 3

Antibiotic Therapy

• Ampicillin 200 mg/kg/day IV divided every 6 hours (or ceftriaxone 50-100 mg/kg/day IV once daily as alternative) 1, 2
• Add azithromycin 10 mg/kg PO/IV on day 1, then 5 mg/kg daily for days 2-5 to cover atypical pathogens 2, 4
• Obtain blood cultures x2 before initiating antibiotics 2

The combination of a beta-lactam with a macrolide provides coverage for both typical bacterial pathogens (particularly Streptococcus pneumoniae) and atypical organisms (Mycoplasma pneumoniae, Chlamydophila pneumoniae) that are common in school-age children 1, 5.

Oxygen Therapy

• Administer supplemental oxygen if SpO2 <92% on room air 1, 2
• Titrate oxygen to maintain SpO2 >92% 1, 2
• Monitor continuously with pulse oximetry 2

Fluid Management

• Calculate maintenance fluids and administer IV fluids at 80% of maintenance to avoid complications from inappropriate ADH secretion 2
• Monitor serum electrolytes daily 2

Diagnostic Studies

• Complete blood count with differential 2
• Basic metabolic panel to monitor electrolytes 2
• Blood cultures x2 before antibiotics 2
• Chest radiography if not already obtained (though diagnosis can be clinical) 1

Supportive Care

• Position patient in supported sitting position to improve lung expansion and respiratory symptoms 2
• Acetaminophen 15 mg/kg/dose PO/PR every 4-6 hours PRN for fever >38.5°C or pain 2
• Ibuprofen 10 mg/kg/dose PO every 6-8 hours PRN for fever or pain 2
• Avoid chest physiotherapy, postural drainage, percussion, or deep breathing exercises 2

Reassessment Criteria

• Reassess clinically at 48-72 hours to evaluate for expected improvement 1, 2
• If no clinical improvement after 48 hours on antibiotics, consider 2:
  • Parapneumonic effusion or empyema
  • Resistant organisms
  • Alternative diagnosis
  • Other complications

Common Pitfalls

The most critical error is delaying appropriate antibiotic therapy. At age 7, bacterial pathogens remain important causes of CAP despite the increasing recognition of viral etiologies 6. While viruses are detected in up to 40% of hospitalized CAP cases, empiric antibacterial coverage is still warranted given the difficulty in distinguishing bacterial from viral pneumonia clinically 5, 6.

Avoid over-resuscitation with fluids, as pneumonia patients are at risk for SIADH 2. The 80% maintenance fluid rate helps prevent hyponatremia while maintaining adequate hydration.

Do not use severity of illness scores as the sole criterion for ICU admission—clinical judgment incorporating respiratory status, hemodynamics, and overall appearance is paramount 3.