Admitting Orders for 4-Year-Old with Community-Acquired Pneumonia
This child requires intravenous antibiotics due to vomiting and inability to tolerate oral medications, combined with concerning features including recurrent respiratory infections and systemic symptoms. 1
Immediate Assessment and Monitoring
- Vital signs monitoring: Assess respiratory rate (tachypnea defined as >40 breaths/min for age 4), oxygen saturation, work of breathing (retractions, nasal flaring, grunting), and temperature 2
- Oxygen therapy: Initiate supplemental oxygen to maintain SpO2 >92% 2
- Hydration status: Monitor for dehydration given 3-day history of vomiting and reduced oral intake 2
- Weight-based calculations: All medication dosing based on 19.5 kg body weight 3
Antibiotic Selection and Dosing
Intravenous ampicillin or cefuroxime/cefotaxime is indicated as first-line therapy given the vomiting and inability to absorb oral antibiotics. 1
Primary antibiotic choice:
- IV ampicillin is preferred if the child is fully immunized with Haemophilus influenzae type b and Streptococcus pneumoniae conjugate vaccines AND local penicillin resistance is minimal 1, 4
- IV ceftriaxone or cefotaxime should be used if immunization status is incomplete or uncertain, or if there is significant local penicillin resistance 1, 4
Critical consideration for this patient:
- History of recurrent LRTI with recent co-amoxiclav use raises concern for resistant organisms or underlying host factors 1
- Consider adding vancomycin or clindamycin if community-acquired MRSA is suspected based on local epidemiology or clinical severity 1, 4
Specific dosing (19.5 kg patient):
- Ampicillin: Standard IV dosing for pneumonia
- Ceftriaxone: 50 mg/kg/day IV once daily (975 mg daily) OR
- Cefotaxime: Age-appropriate IV dosing divided every 8 hours 1
Switching to Oral Therapy
Plan to switch from IV to oral antibiotics when the child shows clear clinical improvement, typically within 48-72 hours. 1
Criteria for oral switch:
- Afebrile for 24 hours 1
- Improved respiratory rate and work of breathing 1, 2
- Tolerating oral intake without vomiting 1
- Oxygen saturation stable on room air 2
Oral antibiotic upon switch:
- High-dose amoxicillin 90 mg/kg/day divided twice daily (1755 mg/day = 877.5 mg BID, round to 875 mg BID) 1, 3, 4
- Alternative: Amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) if broader coverage desired given recurrent infections 1, 4
Re-evaluation Protocol
If the child remains febrile or unwell 48-72 hours after admission, mandatory re-evaluation is required. 1, 2
Investigate for:
- Inadequate antibiotic dosing or inappropriate drug selection 1
- Complications: Parapneumonic effusion, empyema (obtain chest ultrasound if suspected), lung abscess 1
- Host factors: Immunosuppression, cystic fibrosis, or other underlying conditions given the history of recurrent LRTI 1
- Resistant organisms: Consider broader spectrum coverage or infectious disease consultation 1
Supportive Care Orders
- IV fluids: Maintenance fluids if unable to maintain adequate oral hydration 2
- Antipyretics: Acetaminophen or ibuprofen for fever and comfort 2
- Minimal handling: Reduce metabolic demands and oxygen requirements 2
- NPO initially if vomiting persists, advance diet as tolerated 1
Diagnostic Workup
- Chest radiograph: Confirm pneumonia diagnosis 2
- Pulse oximetry: Continuous or frequent monitoring 2
- Blood culture: Prior to antibiotic administration if feasible 1
- Complete blood count: Assess for leukocytosis 1
Treatment Duration
- Total antibiotic course of 7 days for uncomplicated CAP (IV + oral combined) 3, 2
- Duration may need extension if complications develop or slow clinical response 1
Special Considerations for This Patient
The history of recurrent LRTI (2 pneumonia admissions in past year) mandates investigation for underlying predisposing conditions after acute illness resolves. 1