Bronchopneumonia

Patchy, multifocal pneumonia that starts in the bronchi and bronchioles and spreads to adjacent alveoli, producing scattered consolidation in one or both lungs, usually lower zones. It differs from lobar pneumonia, in which a whole lobe is uniformly consolidated.

• It is typical in infants and young children, the elderly, bedridden patients, patients with aspiration risk, post-operative patients, those with chronic lung disease, malnutrition or HIV, and as a complication of measles, whooping cough and influenza.
• Organisms: Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, Klebsiella and other Gram negative bacilli (hospital and elderly), anaerobes (aspiration) and respiratory viruses. In children under 5 in Africa and Asia it is a leading cause of death.
• Mortality is about 5 to 15% in admitted adults and about 2 to 3% in admitted children (higher in malnourished children and in those with HIV).

• Adults: fever, productive cough, dyspnoea, malaise, confusion in the elderly. Children: fever, fast breathing, cough, chest indrawing, grunting, nasal flaring, poor feeding, cyanosis.
• Signs: patchy crackles and rhonchi, bronchial breathing in areas, tachypnoea (children: 60 or more per minute under 2 months, 50 or more at 2 to 11 months, 40 or more at 1 to 5 years), hypoxaemia.
• Differential diagnosis: viral bronchiolitis, asthma, tuberculosis, pulmonary oedema, aspiration pneumonitis, pulmonary embolism, foreign body in a child, lung abscess, interstitial lung disease, pertussis.
• Complications: empyema, lung abscess, pneumatocele, pneumothorax, respiratory failure, sepsis, meningitis, bronchiectasis (recurrent or neglected infection), and in children failure to thrive.

• Chest X-ray: patchy, bilateral or multifocal peribronchial opacities, often lower zones, with air trapping in children; effusion in some.
• Pulse oximetry on all patients (SpO2 less than 92% marks severe disease; less than 90% in children is an indication for oxygen).
• Blood tests for admitted patients: full blood count, CRP, urea and electrolytes, glucose, HIV test, blood culture; sputum culture in adults.
• Xpert MTB/RIF in adults with prolonged cough or HIV, and in children with a poor response or contact history. Look for malnutrition and HIV in every child.
• CT chest and bronchoscopy for non-response, suspected foreign body, or recurrent infection.

• Adults, community onset (choose by severity):
  • Non-severe: amoxicillin 500 mg to 1 g orally three times daily for 5 days, or doxycycline 200 mg then 100 mg twice daily.
  • Moderate: amoxicillin 1 g IV or orally three times daily plus clarithromycin 500 mg twice daily for 7 days.
  • Severe: ceftriaxone 2 g IV daily plus clarithromycin 500 mg IV twice daily; add vancomycin 15 to 20 mg/kg IV every 8 to 12 hours (trough 15 to 20 mg/L) when Staphylococcus aureus is likely.
  • Hospital onset or aspiration with risk of resistant organisms: piperacillin tazobactam 4.5 g IV every 6 hours or meropenem 1 g IV every 8 hours.
• Children under 5:
  • Fast breathing without danger signs: amoxicillin dispersible 40 to 50 mg/kg per dose twice daily for 3 to 5 days, with review at 2 days.
  • Severe pneumonia (chest indrawing, danger signs): ampicillin 50 mg/kg IV every 6 hours plus gentamicin 7.5 mg/kg IV once daily for 5 days, then oral amoxicillin to complete 7 to 10 days; ceftriaxone 50 to 100 mg/kg/day (maximum 4 g) if treatment fails or Staphylococcus aureus or Gram negative infection is suspected, with cloxacillin 50 mg/kg every 6 hours added when staphylococcal infection is likely.
  • HIV-infected or exposed infants under 1 year with severe pneumonia: add high dose co-trimoxazole (trimethoprim 8 mg/kg and sulfamethoxazole 40 mg/kg per dose every 8 hours for 21 days) for presumed Pneumocystis pneumonia, with prednisolone 1 to 2 mg/kg/day for 5 to 7 days then taper in moderate to severe hypoxaemia.
  • Measles and malnutrition: vitamin A 200,000 units orally once daily for 2 days (100,000 units under 12 months, 50,000 units under 6 months); treat malnutrition with therapeutic feeds.
• Supportive care:
  • Oxygen to SpO2 94% or more (92% or more in children), via nasal prongs or high flow; continuous positive airway pressure for children in respiratory distress where available.
  • Paracetamol 1 g four times daily in adults and 15 mg/kg per dose every 6 hours in children; cautious IV fluids at maintenance (restrict in children with pneumonia because of inappropriate antidiuretic hormone secretion).
  • Enoxaparin 40 mg SC daily in admitted adults; chest physiotherapy; nutrition; bronchodilators only for wheeze (salbutamol 100 to 200 micrograms by spacer).
• Duration: adults 5 to 7 days for non-severe and 7 to 10 days for severe disease; 14 days or more for Staphylococcus aureus, Gram negative infection or empyema.
• Failure to improve at 48 to 72 hours: review the diagnosis, check for empyema, abscess, tuberculosis, HIV, foreign body and resistant organisms, and broaden antibiotics.
• Empyema: chest drain, intrapleural alteplase 10 mg plus dornase alfa 5 mg twice daily for 3 days (adults), or surgical debridement.
• Prevention: pneumococcal and Haemophilus influenzae type b vaccination, measles vaccination, exclusive breastfeeding for 6 months, avoiding household smoke, zinc supplementation in children (20 mg daily for 10 to 14 days during diarrhoea), co-trimoxazole prophylaxis in HIV, adult pneumococcal and annual influenza vaccination.
• Special groups:
  • Pregnancy: amoxicillin or ceftriaxone with azithromycin 500 mg daily; avoid doxycycline and fluoroquinolones.
  • Elderly and bedridden patients: reposition, mobilise, oral hygiene, swallow assessment.
  • Renal impairment: adjust vancomycin, gentamicin and piperacillin tazobactam.
• Red flags: SpO2 less than 90%, inability to feed or drink, convulsions, lethargy, severe chest indrawing, cyanosis, shock, persistent fever beyond 72 hours.
• Follow up: review at 48 hours and at 2 to 6 weeks; chest X-ray at 6 weeks for smokers over 50 and for children with recurrent or non-resolving disease; HIV test, growth monitoring and vaccination update.