Pediatric Primary Care Case Studies (97 page)

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Hypoxemia:
Oxygen saturation consistently less than 92% on room air

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Dehydration
or inability to maintain oral hydration

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Moderate to severe respiratory distress:
Respiratory rate > 70 breaths/min in infants less than 12 months or > 50 breaths/min in older children, difficulty breathing, apnea, or grunting

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Toxic appearance

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Failure of outpatient therapy:
Worsening or no response in 24 to 72 hours

Children who have none of these features can be treated as outpatients.

How do you plan to treat this patient’s pneumonia?

Based on the patient’s age, history, and physical exam, the most likely organism for her pneumonia is
Mycoplasma.
A macrolide is the drug of choice. Azithromycin is recommended most often because of its ease of administration, with once daily dosing for 5 days (Durbin & Stille, 2008). Usual dosage for azithromycin is 10 mg/kg QD day 1, then 5 mg/kg QD days 2–5. A more cost-effective alternative is erythromycin 50 mg/kg per day divided Q 6 hours for 10 days; maximum dose 2 g/day. For children who are older than 8 years, doxycycline is an alternative. The dose for doxycycline is 4 mg/kg per day in two divided doses for 10 days; maximum 200 mg/day.

You write a prescription for azithromycin 230 mg PO day 1, then 115 mg PO days 2–5 for pneumonia and instruct the father to follow up with you in 24 hours either by phone or office visit if either parent has concerns.

Most children have an uneventful recovery, but it is important to inform parents that their child’s cough can last for several weeks (Brady, 2009).

Educational plan: What will you do to educate the father about pneumonia and its management?

You discuss the following with Mr. Dixon:

   Explain the diagnosis and pathophysiology of pneumonia.

   Inform the father of the name, dose, frequency, and duration of the antibiotic. Review the dosage of acetaminophen and frequency of its administration.

   Discuss that over-the-counter decongestants should not be given to the child because of dangerous side effects

   Emphasize the need to finish all antibiotics, even if the child is feeling better and fever subsides. Alert Mr. Dixon to the fact that with azithromycin exposure to sunlight (photosensitivity) may cause severe sunburn and skin rashes. Protection from the sun is advisable (e.g., use of sunscreen and wearing of protective clothing).

   Advise the father that uncomplicated bacterial pneumonia should improve within 48 hours.

   Teach the father how to monitor for signs of increased respiratory distress.

   Educate the father that cough can last several weeks.

   Discuss the need to keep Mary hydrated, and emphasize that he should not be worried about her appetite, which should return in 2 to 3 days when she is feeling better.

When do you want to see this patient back again?