What is the next step in treatment for a 10-year-old child with a history of cardiac surgery (three times) presenting with a 5-day history of cough, shortness of breath (SOB), and hypoxemia (oxygen saturation 93%), who has tested negative for influenza and COVID-19?

From the Guidelines

The child should be immediately referred to the emergency department or a pediatric cardiologist for evaluation and treatment, with supplemental oxygen provided to maintain oxygen saturation above 94%. Given the child's history of multiple cardiac surgeries and current presentation of cough, shortness of breath, and oxygen saturation of 93%, there is a high risk for complications such as heart failure exacerbation, post-cardiac surgery complications, or respiratory infection affecting their compromised cardiopulmonary system 1. The child's symptoms and oxygen saturation level indicate the need for prompt medical attention to prevent further deterioration.

The child requires a comprehensive evaluation, including:

• Chest imaging, likely a chest X-ray, to assess for any respiratory complications
• Complete blood count to evaluate for any signs of infection or inflammation
• Potentially, a cardiac assessment including an echocardiogram to evaluate cardiac function

While awaiting transfer, it is essential to provide supplemental oxygen to maintain oxygen saturation above 94% and closely monitor vital signs, including heart rate, respiratory rate, and blood pressure 1. The child's clinical appearance and behavior should also be closely monitored, as these can be indicative of the severity of illness 1.

According to the guidelines for the management of community-acquired pneumonia in infants and children older than 3 months of age, a child with an oxygen saturation of less than 92% on inspired oxygen of ≥0.50 should be admitted to an ICU 1. Although the child's oxygen saturation is currently 93%, the history of cardiac surgery and presence of respiratory symptoms warrant close monitoring and prompt evaluation to prevent potential complications.

The guidelines also recommend that children with impending respiratory failure, sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities 1. Given the child's complex medical history and current symptoms, it is crucial to prioritize their safety and provide timely medical intervention to prevent adverse outcomes.

From the FDA Drug Label

Pediatric Patients: (See PRECAUTIONS—Pediatric Use and CLINICAL STUDIES IN PEDIATRIC PATIENTS.) Community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy. NOTE: Azithromycin should not be used in pediatric patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following: patients with cystic fibrosis, patients with nosocomially acquired infections, patients with known or suspected bacteremia, patients requiring hospitalization, or patients with significant underlying health problems that may compromise their ability to respond to their illness (including immunodeficiency or functional asplenia). The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with community-acquired pneumonia is 10 mg/kg as a single dose on the first day followed by 5 mg/kg on Days 2 through 5.

The patient is a 10-year-old child with a history of cardiac surgery, presenting with a 5-day cough, shortness of breath, and oxygen saturation of 93%. Given the patient's symptoms and the fact that they have tested negative for influenza and COVID-19, community-acquired pneumonia is a potential diagnosis.

• The patient's history of cardiac surgery and current symptoms may indicate a more complex clinical picture, but based on the information provided from the drug label, azithromycin could be considered for the treatment of community-acquired pneumonia in pediatric patients.
• However, it's crucial to assess whether the patient has any underlying conditions that might make them inappropriate for oral therapy, such as significant underlying health problems.
• The recommended dose for a pediatric patient with community-acquired pneumonia is 10 mg/kg as a single dose on the first day followed by 5 mg/kg on Days 2 through 5 2.
• Given the patient's age and weight are not specified, the exact dose cannot be determined from the provided information.
• It is also important to consider that the decision to use azithromycin should be based on the susceptibility of the causative organism and local epidemiology, and culture and susceptibility tests should be performed before treatment to determine the causative organism and its susceptibility to azithromycin 2.

From the Research

Patient Assessment and Oxygen Therapy

• The patient is a 10-year-old child with a history of cardiac surgery, presenting with a 5-day cough, shortness of breath (SOB), and an oxygen saturation of 93% 3, 4, 5.
• The patient has tested negative for influenza and COVID-19, which helps to rule out these common causes of respiratory symptoms.

Oxygen Therapy Considerations

• According to the AARC Clinical Practice Guideline, the target oxygen saturation range for most hospitalized patients is 94-98% 4.
• Since the patient's oxygen saturation is 93%, supplemental oxygen therapy may be considered to increase their oxygen saturation to the target range.
• The choice of oxygen device and flow rate will depend on the patient's individual needs and clinical assessment 3, 6.

Antibiotic Therapy Considerations

• Although the patient's symptoms suggest a respiratory infection, there is no clear indication for antibiotic therapy at this time, especially since the patient has tested negative for influenza and COVID-19.
• If antibiotic therapy is considered, azithromycin may be an option, but its pharmacokinetics and potential for inducing bacterial resistance should be taken into account 7.

Next Steps in Treatment

• Further evaluation and monitoring of the patient's respiratory status, including oxygen saturation and clinical symptoms, are necessary to determine the best course of treatment.
• Consideration of supplemental oxygen therapy and other supportive treatments, such as bronchodilators or antipyretics, may be necessary to manage the patient's symptoms and improve their oxygen saturation.