Hospital Management of Bronchopneumonia in a 5-Year-Old Child
For this 5-year-old child (18 kg) with bronchopneumonia requiring hospitalization, initiate intravenous ampicillin 150-200 mg/kg/day divided every 6 hours (675-900 mg every 6 hours) OR ceftriaxone 50-100 mg/kg/day divided every 12-24 hours (900-1800 mg daily), along with IV fluids for hydration given the low oral intake and general weakness. 1
Antibiotic Selection and Dosing
First-Line Parenteral Therapy
Ampicillin is the preferred initial parenteral agent for typical bacterial pneumonia at 150-200 mg/kg/day divided every 6 hours, which translates to 675-900 mg every 6 hours for this 18 kg child 1
Ceftriaxone is an equally appropriate alternative at 50-100 mg/kg/day, administered as 900-1800 mg once or twice daily, particularly useful if β-lactamase-producing organisms are suspected 1
Cefotaxime 150 mg/kg/day every 8 hours (900 mg every 8 hours) is another acceptable alternative with similar coverage 1
Transition to Oral Therapy
Once the child shows clinical improvement (typically within 48-72 hours), transition to oral step-down therapy: 1, 2
High-dose amoxicillin 90 mg/kg/day divided twice daily (810 mg twice daily) is the preferred oral agent for completing the treatment course 1, 3, 2
Amoxicillin-clavulanate 90 mg/kg/day (amoxicillin component) divided twice daily is indicated if β-lactamase-producing H. influenzae is suspected or if the child has not responded adequately to amoxicillin alone 1, 3
Alternative oral agents include cefdinir 14 mg/kg/day (252 mg daily) or other oral cephalosporins if β-lactam allergy is not a concern 1, 4
Supportive Care Management
Hydration and Nutrition
IV fluid therapy is essential given the combination of fever for 3-4 days, nausea, and poor oral intake, which places this child at risk for dehydration 1
Maintenance IV fluids should be calculated based on weight (approximately 1400 mL/day for 18 kg using standard pediatric formulas) 1
Monitor for clinical improvement in hydration status and gradually advance oral intake as tolerated 2
Monitoring Parameters
Assess for clinical improvement within 48-72 hours: resolution of fever, decreased respiratory distress, improved oral intake 2, 5
If no improvement occurs within 48-72 hours, reevaluation is mandatory and consideration of resistant organisms or complications is necessary 1, 2
Monitor for development of danger signs: increased work of breathing, hypoxemia, altered mental status, inability to feed 1
Treatment Duration
Total antibiotic duration should be 7-10 days for uncomplicated community-acquired pneumonia 1, 2
The parenteral portion typically lasts 2-3 days until clinical improvement is evident, followed by oral completion 1, 2
Treatment should continue for a minimum of 48-72 hours beyond symptom resolution 2
Special Considerations for This Case
Atypical Pathogen Coverage
Given the age of 5 years and the 3-4 day fever duration, consider adding azithromycin if atypical pathogens (Mycoplasma pneumoniae) are suspected based on clinical features 1
Azithromycin dosing: 10 mg/kg IV on days 1-2, then transition to 5 mg/kg/day orally for days 3-5 (180 mg on day 1, then 90 mg daily) 1
However, typical bacterial pathogens remain more common in this age group with radiographic bronchopneumonia, so β-lactam therapy should not be omitted 1
Nausea Management
The nausea without vomiting may be related to the infection itself or post-tussive in nature 1
Antiemetics may be considered if nausea interferes with oral intake, though they are not routinely necessary 1
IV hydration will help manage this symptom while maintaining adequate fluid balance 1
Common Pitfalls to Avoid
Do not use narrow-spectrum therapy initially in a hospitalized child with bronchopneumonia, as this suggests moderate-to-severe disease requiring broad coverage 1
Avoid fluoroquinolones (levofloxacin, moxifloxacin) as first-line agents in children due to concerns about cartilage toxicity, reserving them for resistant organisms 1
Do not delay IV hydration while waiting for oral intake to improve, as dehydration can worsen clinical outcomes 1
Ensure appropriate dosing based on current weight (18 kg), not age-based dosing, to achieve adequate drug concentrations 1, 3, 2