Community-acquired pneumonia — formative SAQs

SAQ 1 (10 marks)

A 3-year-old girl is brought to the emergency department with three days of fever and cough and one day of fast breathing. She is alert but flushed, her respiratory rate is 42 per minute with mild subcostal recession, there are focal crackles and reduced air entry at the right base, and her oxygen saturation is 96 percent on air. She is drinking about three-quarters of normal. [1] [2]

1. State your assessment of severity and how you graded it. (3) [2]
2. Outline your investigation and initial treatment. (4) [1] [5]
3. Describe how you would decide on disposition and what advice you would give. (3) [2]

Model answer — SAQ 1

(1) Severity (3). This is non-severe community-acquired pneumonia: a febrile child with focal chest signs and fast breathing for age, but who is alert, feeding at around three-quarters of normal and saturating at 96 percent on air with only mild recession. I grade severity by integrating the respiratory rate against the age threshold, the degree of chest indrawing, oxygenation and feeding rather than a single number, and I would reassess her after antipyresis to read the trajectory. [2]

(2) Investigation and treatment (4). She does not need routine investigation. In non-severe pneumonia a chest radiograph, bloods and microbiology do not change management, and a randomised trial showed imaging in ambulatory children did not improve outcome, so I would treat clinically. I would start first-line oral amoxicillin at an appropriate weight-based dose, give antipyresis and encourage fluids, and I would not use the intravenous route because she can absorb oral therapy. I would keep the course short, as short standard-dose regimens are non-inferior for non-severe disease. [1] [5]

(3) Disposition and advice (3). She can be managed at home because she is non-severe, feeding adequately, saturating well and has a family able to give oral antibiotics and return if needed. I would give concrete safety-net advice: return urgently if her breathing becomes harder or faster, if she will not drink or has far fewer wet nappies, if she becomes drowsy or blue, or if the fever persists beyond about forty-eight hours. I would arrange review at around forty-eight hours to confirm improvement. [2] [1]

SAQ 2 (10 marks)

A 7-year-old boy admitted five days ago with pneumonia and started on intravenous antibiotics still has high fevers, worsening breathlessness and a dull, quiet right hemithorax. He was previously treated with oral amoxicillin by his general practitioner without improvement. [1] [4]

1. What complication do you suspect and how would you confirm it? (3) [4]
2. Outline your management of this complication. (4) [4] [1]
3. He is 7 years old with a gradual-onset dry cough before this illness; how does this influence your antibiotic thinking? (3) [1]

Model answer — SAQ 2

(1) Complication and confirmation (3). I suspect a parapneumonic effusion progressing to an empyema, because his fever persists beyond forty-eight to seventy-two hours of appropriate antibiotics, his respiratory distress is worsening, and one hemithorax is dull and quiet. I would confirm and characterise the collection with a chest radiograph and, importantly, a pleural ultrasound, which best defines the size, loculation and character of the fluid and guides whether and how to drain it. [4]

(2) Management (4). A small effusion may settle with continued appropriate antibiotics, but a significant or purulent collection needs drainage. I would continue intravenous antibiotics with cover appropriate to a complicated pneumonia, involve the respiratory and surgical teams, and drain a significant empyema by chest drain with intrapleural fibrinolytics or by thoracoscopic surgery, guided by local expertise and the character of the fluid. I would provide analgesia, oxygen to keep saturations at or above target, and nutritional support, and step down to oral therapy once he is improving and afebrile. [4] [1]

(3) Age and atypical cover (3). At 7 years, and with a preceding gradual-onset dry cough and failure of amoxicillin, atypical infection with Mycoplasma pneumoniae becomes an important consideration, because it does not respond to amoxicillin. I would add a macrolide such as azithromycin to cover atypical organisms while continuing pneumococcal cover, since school-age children are the group in whom atypical pneumonia is most likely and in whom first-line beta-lactam failure should prompt this step. [1]