What is the treatment for a 13-year-old with bronchopneumonia?

Treatment of Bronchopneumonia in a 13-Year-Old

For a 13-year-old with bronchopneumonia (community-acquired pneumonia), amoxicillin 90 mg/kg/day divided into 2 doses is the first-line antibiotic treatment, with consideration of adding a macrolide if atypical pathogens like Mycoplasma pneumoniae are suspected. 1, 2, 3

Initial Assessment and Treatment Decision

Determine Need for Hospitalization vs. Outpatient Management

Hospitalize if any of the following are present:

• Oxygen saturation <92% 1, 2, 4
• Respiratory rate >50 breaths/min (for this age group) 2, 4
• Increased work of breathing, grunting, or respiratory distress 1, 2
• Signs of dehydration or inability to maintain oral intake 2, 4
• Altered mental status 1

Outpatient management is appropriate if:

• Oxygen saturation ≥92% on room air 2
• No respiratory distress 2
• Able to maintain adequate oral hydration 2
• Family can provide appropriate observation 2

Antibiotic Selection

For Outpatient Management (Mild-Moderate Disease)

First-line therapy:

• Amoxicillin 90 mg/kg/day divided into 2 doses for 7-10 days 2, 4
• This provides appropriate coverage for Streptococcus pneumoniae, the most common bacterial pathogen 2

Consider adding a macrolide if atypical pathogens suspected:

• Clinical clues for atypical pneumonia (Mycoplasma pneumoniae, Chlamydophila pneumoniae) include: gradual onset, prominent cough, lack of toxic appearance, and school-age presentation 5
• Azithromycin 500 mg on Day 1, then 250 mg daily on Days 2-5 3
• Alternative: Azithromycin 500 mg daily for 3 days 3

For Hospitalized Patients (Moderate-Severe Disease)

Intravenous antibiotics are indicated:

• Ampicillin or penicillin G as first-line 4
• Ceftriaxone or cefotaxime as alternatives 4
• Add vancomycin or clindamycin if MRSA suspected (necrotizing pneumonia, empyema, severe illness) 4

Supportive Care

Essential supportive measures include:

• Supplemental oxygen to maintain saturation >92% 1, 4
• Adequate hydration through oral fluids; IV fluids at 80% basal levels if unable to maintain oral intake 6, 4
• Antipyretics (acetaminophen or ibuprofen) for fever control and comfort 2
• Adequate rest 2

Do NOT use:

• Chest physiotherapy (not beneficial) 2
• Over-the-counter cough and cold medications (lack efficacy, potential harm) 2

Monitoring and Follow-Up

Expected Clinical Response

• Re-evaluate at 48-72 hours if not improving 1, 6
• Fever should begin resolving within 48 hours for typical bacterial pneumonia 6
• Atypical pneumonia may require 2-4 days for fever resolution 6

Signs of Treatment Failure or Complications

Reassess and escalate care if:

• Persistent or worsening fever after 48-72 hours 1
• Development of hypothermia (may indicate sepsis or shock) 6
• Worsening respiratory status 1
• New oxygen requirement or increasing oxygen needs 1
• Poor feeding or signs of dehydration 6

Management of non-responders includes:

• Clinical and laboratory assessment to determine need for higher level of care 1
• Imaging evaluation (chest X-ray or ultrasound) to assess for complications like parapneumonic effusion, abscess, or necrotizing pneumonia 1
• Consider changing antibiotics: if started on amoxicillin alone, add macrolide for atypical coverage 6
• Investigate for resistant organisms or secondary infection 1

Management of Complications

Parapneumonic Effusion

If effusion develops:

• Small effusion (<10mm): Continue antibiotics alone, no drainage needed 1
• Moderate effusion: Obtain pleural fluid for culture via thoracentesis or chest tube 1
• Large effusion (>50% hemithorax): Chest tube with or without fibrinolytics, or VATS if not responding 1
• Antibiotic duration for complicated effusions: 2-4 weeks 1

Pulmonary Abscess or Necrotizing Pneumonia

• Initially treat with IV antibiotics 1
• Most will drain through bronchial tree without surgical intervention 1
• Consider image-guided drainage only for well-defined peripheral abscesses 1

Discharge Criteria (If Hospitalized)

Patient is ready for discharge when ALL of the following are met:

• Clinical improvement with decreased fever for 12-24 hours 1
• Oxygen saturation >90% on room air for 12-24 hours 1
• Stable mental status 1
• No increased work of breathing, tachypnea, or tachycardia 1
• Able to tolerate oral antibiotics and maintain hydration 1

Common Pitfalls to Avoid

• Do not reflexively prescribe antibiotics for all pneumonia cases in younger children, as most are viral; however, at age 13, bacterial etiology is more common and antibiotics are typically indicated 2, 5
• Do not assume hypothermia means improvement—it may signal worsening sepsis or shock 6
• Do not delay re-evaluation at 48-72 hours if patient not improving 1, 6
• Do not forget to consider atypical pathogens in school-aged children, especially if gradual onset and prominent cough 5