Staphylococcal pneumonia


Pneumonia due to Staphylococcus aureus affecting young children, often those in a poor general condition (malnutrition, skin lesions, etc.). Staphylococcal pneumonia is a classic complication of measles.

Clinical features

– General signs: change in overall condition, pallor, high fever or hypothermia, frequently signs of shock; presence of skin lesions (point of bacterial entry), however, skin lesions may be absent.
– Gastrointestinal signs: nausea, vomiting, diarrhoea, painful abdominal distention.
– Respiratory signs: dry cough, tachypnoea, signs of distress (nasal flaring, chest indrawing). Pulmonary auscultation is often normal; sometimes dullness indicating pleural effusion.

If possible, take a chest X-ray: the presence of bullae confirms the diagnosis. Pleural effusion, often unilateral, may also be seen.

Treatment

Treatment is urgent as patients deteriorate quickly: hospitalise.

– Antibiotic treatment: if staphylococcal aetiology cannot be confirmed or while waiting for confirmation, a broad spectrum antibiotic therapy is recommended:
ceftriaxone IM or slow IV1 (at least 3 minutes): 50 mg/kg once daily
cloxacillin IV infusion (60 minutes)2
Neonates 0 to 7 days (< 2 kg): 50 mg/kg every 12 hours
Neonates 0 to 7 days (≥ 2 kg): 50 mg/kg every 8 hours
Neonates 8 days to < 1 month (< 2 kg): 50 mg/kg every 8 hours
Neonates 8 days to < 1 month (≥ 2 kg): 50 mg/kg every 6 hours
Children 1 month and over: 25 to 50 mg/kg every 6 hours (max. 8 g daily)

After clinical improvement3 , 3 days with no fever, and drain removal if any, switch to amoxicillin/clavulanic acid PO to complete 10 to 14 days. Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin: 50 mg/kg 2 times daily

In the event of large empyema: same treatment but switch to the oral route after 7 days with no fever and treat for 3 weeks.

Clindamycin IV may be an alternative to cloxacillin: 10 mg/kg every 8 hours then switch to clindamycin PO at the same dose, according to the criteria above.

– Fever: paracetamol (Chapter 1).

– Hydration by oral route or infusion or nasogastric tube depending on clinical condition.

– Oxygen at the flow rate required to maintain SpO2 ≥ 90% or, if pulse oxymeter is not available, minimum 1 litre/minute.

– Local disinfection of skin lesions.

– If there is significant pleural effusion: pleural tap with drainage (for pyopneumothorax; insert 2 drains, one anterior and one posterior) or without drainage (for suppurative pleurisy, make repetitive taps with an IV catheter).

Clinical evolution

– There is a serious risk of decompensation from pneumothorax or suppurative pleurisy or pyopneumothorax.

– On a paediatric ward, adequate equipment for urgent pleural drainage should always be available.



Footnotes
Ref Notes
1 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.
2 Cloxacillin powder for injection should be reconstituted in 4 ml of water for injection. Then dilute each dose of cloxacillin in 5 ml/kg of 0.9% sodium chloride or 5 % glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.
3 Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO2, improved appetite and/or activity.