Pneumonia, Community-acquired (CAP)

[Paediatr Child Health 2015;20:441-5, Clin Infect Dis 2011; Aug: e1-52, and Thorax 2011;66:ii1-23]

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Diagnosis

- Chest x ray recommended to confirm diagnosis whenever possible and if deterioration to rule out empyema.

- S. pneumoniae is most common pathogen.

Antibiotic therapy

- Amoxicillin:

• provides the best coverage of all oral β-lactams against S. pneumoniae, even majority of penicillin-resistant strains.

• no activity against S. aureus, β-lactamase (+) H. influenzae, M. catarrhalis, M. pneumoniae, or C. pneumoniae.

- Macrolides:

• significant macrolide resistance in S. pneumoniae

• poor Haemophilus coverage

• recent (within previous 3 months) macrolide use may result in multidrug resistant S. pneumoniae

• monotherapy with macrolides has uncertain efficacy for pneumococcal bacteremia (clinical history of rigors/positive blood culture).

- In sickle cell anemia, overwhelming pneumococcal infection can occur and Mycoplasma pneumoniae is common. There may be a small risk of hemolysis from ceftriaxone, so cefotaxime is preferred for inpatients (ceftriaxone for outpatients), plus a macrolide if 5 years of age or older.

- Switch to oral therapy if:

• afebrile

• clinically improving

• tolerating oral intake

• no complications (e.g. empyema).