Pneumonia in children over 5 years and adults

The most common causes are viruses, pneumococcus, and Mycoplasma pneumoniae.

Clinical features

• Cough, with or without purulent sputum, fever, thoracic pain, tachypnoea
• On pulmonary auscultation: decreased vesicular breath sounds, dullness, localised foci of crepitations, sometimes bronchial wheeze.

Sudden onset with high fever (higher than 39 °C), thoracic pain and oral herpes are suggestive of pneumococcal infection. Symptoms may be confusing, particularly in children with abdominal pain, meningeal syndrome, etc.

Signs of severity (severe pneumonia) include:

• Cyanosis (lips, oral mucosa, fingernails)
• Nasal flaring
• Intercostal or subclavial indrawing
• RR > 30 breaths/minute
• Heart rate > 125 beats/minute
• Altered level of consciousness (drowsiness, confusion)

Patients at risk include the older patients, patients with heart failure, sickle cell disease or severe chronic bronchitis; immunocompromised patients (severe malnutrition, HIV infection with CD4 < 200).

Treatment

Severe pneumonia (inpatient treatment)

ceftriaxone IM or slow IV a Citation a. The solvent of ceftriaxone for IM injection contains lidocaine. Ceftriaxone reconstituted using this solvent must never be administered by IV route. For IV administration, water for injection must always be used. (3 minutes)
Children: 50 mg/kg once daily
Adults: 1 g once daily
The treatment is given by parenteral route for at least 3 days then, if the clinical condition has improved b Citation b. Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO₂, improved appetite and/or activity.  and oral treatment can be tolerated, switch to amoxicillin PO to complete 7 to 10 days of treatment:
Children: 30 mg/kg 3 times daily (max. 3 g daily)
Adults: 1 g 3 times daily
or
ampicillin slow IV (3 minutes) or IM
Children: 50 mg/kg every 6 hours
Adults: 1 g every 6 to 8 hours
Ampicillin is preferably administered in 4 divided doses. If the context does not permit it, the daily dose must be divided in at least 3 doses.
The treatment is given by parenteral route for at least 3 days then, if the clinical condition has improved b Citation b. Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO₂, improved appetite and/or activity.  and oral treatment can be tolerated, switch to the oral route with amoxicillin PO as above, to complete 7 to 10 days of treatment.

If the clinical condition deteriorates or does not improve after 48 hours of correct administration, administer ceftriaxone as above + cloxacillin IV infusion:
Children: 25 to 50 mg/kg every 6 hours
Adults: 2 g every 6 hours
After clinical improvement and 3 days with no fever, switch to amoxicillin/clavulanic acid (co-amoxiclav) PO to complete 10 to 14 days of treatment. Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin:
Children < 40 kg: 50 mg/kg 2 times daily
Children ≥ 40 kg and adults:
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)

If the clinical condition does not improve after 48 hours with ceftriaxone + cloxacillin, consider tuberculosis. For the diagnosis, refer to the guide Tuberculosis, MSF.

If tuberculosis is unlikely, continue with ceftriaxone + cloxacillin and add azithromycin (see Atypical pneumonia).

Adjuvant therapy

• Fever: paracetamol PO (Chapter 1).
• Clear the airway (nasal irrigation with 0.9% sodium chloride if needed).
• Oxygen at the flow rate required to maintain SpO₂ ≥ 90% or, if pulse oxymeter is not available, minimum 1 litre/minute.
• Maintain adequate hydration and nutrition.

Pneumonia without signs of severity (outpatient treatment)

amoxicillin PO
Children: 30 mg/kg 3 times daily (max. 3 g daily) for 5 days
Adults: 1 g 3 times daily for 5 days

Follow-up in 48 to 72 hours or sooner if the patient's condition deteriorates:

• If the condition is improving b Citation b. Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO₂, improved appetite and/or activity.  : continue with the same antibiotic to complete treatment.
• If there is no improvement after 3 days of correct administration: add azithromycin (see Atypical pneumonia).
• If the condition is deteriorating: hospitalise and treat as severe pneumonia.