Community-acquired pneumonia — branching viva

Opening

Examiner: A 3-year-old arrives with three days of fever and cough, now breathing fast at 44 per minute with focal right basal crackles, mild recession, feeding three-quarters of normal and saturating 96 percent. How do you approach her? [1]

Candidate: I would make a clinical diagnosis of community-acquired pneumonia — a febrile child with fast breathing for age and focal chest signs — and grade its severity by observation before disturbing her. She has a raised respiratory rate but is alert, feeding adequately and saturating well with only mild recession, which places her in the non-severe band. My plan is oral amoxicillin at home with antipyresis and safety-net advice, and I would deliberately not order routine imaging or bloods. [1] [2]

Branch 1 — investigation and first-line therapy

Examiner: Would you get a chest X-ray to confirm it? [3]

Candidate: No, not in non-severe pneumonia. A chest radiograph does not change management in a well child treated as an outpatient, and a randomised trial in ambulatory children with acute lower respiratory infection showed imaging did not improve clinical outcome. It also cannot reliably separate bacterial from viral pneumonia. I reserve a film for severe, complicated, uncertain, recurrent or non-responding cases or a suspected effusion. [3] [2]

Examiner (probe): What antibiotic, route and duration would you choose, and why? [4]

Candidate: I would give oral amoxicillin as first-line, because it covers the pneumococcus, which is the main treatable cause, and oral therapy is as effective as intravenous therapy for a child well enough to absorb it. I would use a short course, because the SAFER trial showed about five days is non-inferior to a longer course for non-severe pneumonia, which reduces antibiotic exposure without harming outcomes. [4] [1]

Branch 2 — the deteriorating child

Examiner: She is admitted for social reasons and two days later has ongoing high fevers and increasing breathlessness with a dull right base. Reassured that she is on antibiotics? [5]

Candidate: No — persistent fever beyond about forty-eight to seventy-two hours with worsening distress and a dull, quiet hemithorax suggests a parapneumonic effusion or empyema. I would reassess her fully, confirm with a chest radiograph and pleural ultrasound, and involve the respiratory and surgical teams. A small effusion may settle with antibiotics, but a significant empyema needs drainage. [5] [1]

Examiner (probe): How would you manage a confirmed significant empyema? [5]

Candidate: I would continue appropriate intravenous antibiotics, provide oxygen, analgesia and nutritional support, and drain a significant collection either by chest drain with intrapleural fibrinolytics or by thoracoscopic surgery, guided by local expertise and the character of the fluid. Most children recover completely with good long-term lung function, so the prognosis is reassuring despite the alarming course. [5] [1]

Branch 3 — the older child and atypical infection

Examiner: A different patient is 9 years old with a week of gradual dry cough, headache, malaise and only mild chest signs, not responding to amoxicillin. Same approach? [1]

Candidate: No — this picture in a school-age child suggests atypical infection with Mycoplasma pneumoniae, which does not respond to amoxicillin. I would add a macrolide such as azithromycin to cover atypical organisms, since school-age children are the group in whom this is most likely and first-line beta-lactam failure with this pattern should prompt the switch. [1] [2]

Examiner (probe): When would you admit a child with pneumonia? [2]

Candidate: I admit for severe or very severe disease — hypoxia with saturations below ninety-two percent, severe chest indrawing, grunting, an inability to feed, dehydration, cyanosis, apnoea or altered consciousness — and for high-risk children such as young infants, those with significant comorbidity, or those who have failed oral therapy. I also weigh the family's ability to observe and return safely. [2] [1]

Close

Examiner: Summarise your safe approach to childhood pneumonia in one line. [1]

Candidate: Diagnose it clinically, grade it by respiratory rate, indrawing, oxygen and feeding, treat most children with a short course of oral amoxicillin and image only when it will change management, give oxygen and intravenous care for severe disease, and stay alert for atypical infection and for the effusion or empyema behind a persistent fever. [1] [5]