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Referral and warning signs
When to refer
Hospital admission (HC4/H/RR) required for: Severe pneumonia criteria (hypoxia, tachypnea, hypotension, confusion, severe distress). Infants <2 months. Children 2mo-5yr with severe signs (cyanosis, inability to feed, severe indrawing). Failure of outpatient antibiotic therapy. Suspected complications (empyema, abscess). Need for IV fluids/oxygen/supportive care. Significant co-morbidities.
Red flags
- Severe respiratory distress (RR >30 adult, >50/40 child)
- Hypoxia (SpO2 <90-92%) / Cyanosis
- Hypotension (SBP <90 mmHg)
- Confusion / Altered mental status
- Inability to maintain oral intake
- Multi-lobar involvement on CXR
- Presence of significant co-morbidities
Signs and symptoms
- Cough (often productive of purulent or rust-colored sputum)
- Fever, chills, rigors
- Dyspnoea (shortness of breath)
- Tachypnea (rapid breathing)
- Pleuritic chest pain (sharp pain worse with inspiration)
- Malaise, fatigue
- Examination: Tachypnea, fever, tachycardia. Focal chest signs - crackles (rales), bronchial breath sounds, dullness to percussion over consolidation. Increased tactile/vocal fremitus.
- Atypical presentation (esp. elderly/immunosuppressed): Confusion, delirium, falls, worsening of chronic conditions, fewer focal chest signs.
- Infants (<2mo): See specific section (Severe disease).
- Children (2mo-5yr): Cough, fast breathing (≥50 if 2-11mo, ≥40 if 1-5yr), +/- fever, chest indrawing (indicates severe).
- Children (>5yr)/Adults: Cough, fever, tachypnea (>30), chest pain. Severe signs: Chest indrawing, SpO2 <90%, confusion, hypotension, severe distress.
Risk factors
- Age extremes (very young, elderly)
- Smoking
- Chronic lung disease (COPD, asthma, bronchiectasis)
- Immunosuppression (HIV, malignancy, chemotherapy, chronic steroids)
- Chronic illnesses (diabetes, heart failure, liver disease, kidney disease)
- Impaired consciousness / Difficulty swallowing (risk of aspiration)
- Recent viral respiratory infection (e.g., influenza)
- Hospitalization / Mechanical ventilation (HAP/VAP)
- Malnutrition
- Alcoholism
Diagnosis
Clinical assessment
Diagnosis based on clinical presentation (acute respiratory illness with cough, fever, dyspnoea) and focal chest signs on examination. Severity assessment crucial (e.g., using CURB-65 score or specific criteria for children). Differential diagnosis: Acute bronchitis, COPD/Asthma exacerbation, Heart failure/Pulmonary oedema, Pulmonary embolism, Lung cancer, TB, Interstitial lung disease.
Investigations
- Chest X-ray (PA and Lateral): Key investigation. Confirms diagnosis, shows location/extent of infiltrate (consolidation, interstitial pattern), identifies complications (effusion, abscess, cavitation).
- Pulse Oximetry (SpO2): Assess severity/hypoxia.
- Sputum Gram Stain and Culture: May identify bacterial pathogen, guiding targeted therapy (often difficult to obtain good sample, low yield).
- Blood Cultures: Obtain in hospitalized/severe cases before antibiotics.
- Complete Blood Count (CBC): Leucocytosis with left shift common in bacterial pneumonia.
- Urea & Electrolytes, Renal function, Liver function tests.
- Inflammatory markers (CRP): May help assess severity/response.
- Urinary Antigen Tests (S. pneumoniae, Legionella): For specific pathogens (usually hospital setting).
- Viral testing (Influenza, RSV, COVID-19): Especially during outbreaks/epidemics.
- HIV testing (recommended in adults with pneumonia).
- Consider TB testing (Sputum AFB/Xpert) especially if chronic symptoms, specific CXR pattern, or risk factors.
Diagnostic criteria
Clinical presentation consistent with pneumonia PLUS new infiltrate on Chest X-ray. In resource-limited settings, clinical diagnosis based on WHO criteria (e.g., cough + fast breathing +/- chest indrawing in children) is often used.
Management
Non-pharmacological management
- Supportive Care:
- - Oxygen therapy: Titrate to maintain SpO2 >94% (or 88-92% in known COPD).
- - Fluid management: Ensure adequate hydration (oral or IV if needed).
- - Nutritional support.
- - Analgesia/Antipyretics (Paracetamol).
- - Chest physiotherapy (limited evidence for routine use in uncomplicated pneumonia).
Pharmacological treatment
- Antibiotic Therapy: Choice depends on age, severity, likely pathogens, local resistance patterns, co-morbidities.
- - Infants (<2 months): SEVERE - Hospitalize. Ampicillin IV + Gentamicin IV. OR Ceftriaxone IV. (See UCG 5.2.9.1)
- - Children (2 months - 5 years):
- - Non-severe (Fast breathing +/- mild indrawing): Oral Amoxicillin DT 40mg/kg BID for 5 days.
- - Severe (Cyanosis, inability to feed, severe distress, severe indrawing): Hospitalize. IV/IM Ampicillin (or Benzylpenicillin) + IV/IM Gentamicin. If no response/Staph suspected: IV Cloxacillin + IV Gentamicin. If very severe/no response: IV Ceftriaxone. Switch to oral Amoxicillin when improving to complete course. (See UCG 5.2.9.2)
- - Children (>5 years) / Adults - Community Acquired (CAP):
- - Moderate (Ambulatory): Oral Amoxicillin 500mg-1g TID for 5 days. Alternative (allergy/atypical suspected): Doxycycline 100mg BID OR Erythromycin 500mg QID for 7-10 days. (See UCG 5.2.9.3)
- - Severe (Hospitalized): IV Benzylpenicillin 2MU Q6H (or Ampicillin). If no response/severe: IV Ceftriaxone 1-2g OD. If Staph suspected: IV Cloxacillin. Alternative: IV Chloramphenicol. Add macrolide (Erythromycin/Azithromycin) or Doxycycline if atypical pathogen coverage needed.
- Specific Organisms:
- - Staphylococcus aureus: Cloxacillin (IV -> Oral). Vancomycin if MRSA suspected.
- - Klebsiella: Gentamicin +/- Cephalosporin or Ciprofloxacin.
- - Mycoplasma/Chlamydia pneumoniae: Macrolide (Erythromycin/Azithromycin) or Doxycycline.
- - Pneumocystis jirovecii (PCP): High-dose Co-trimoxazole IV/PO + Prednisolone if hypoxic (See HIV section/CV001).
- Duration: Typically 5-7 days for uncomplicated CAP, longer for severe/complicated cases or specific pathogens.
Monitoring
- Monitor vital signs (RR, HR, Temp, BP, SpO2).
- Assess clinical response (fever resolution, improved cough/dyspnoea) within 48-72 hours.
- Monitor for complications (respiratory failure, sepsis, effusion/empyema, abscess).
- Repeat Chest X-ray not routinely needed if clinically improving, consider if slow resolution or complications suspected.
Complications
- Respiratory failure
- Sepsis / Septic shock
- Pleural effusion / Empyema
- Lung abscess
- Necrotizing pneumonia
- Acute Respiratory Distress Syndrome (ARDS)
- Bacteraemia
- Metastatic infection (e.g., meningitis, endocarditis - rare)
- Exacerbation of underlying chronic illness
Prevention
- Vaccinations: Pneumococcal vaccine (PCV for children, PPSV23 for adults/high-risk), Hib vaccine (children), Influenza vaccine (annual), Measles vaccine, Pertussis vaccine.
- Smoking cessation.
- Good hygiene (handwashing).
- Manage underlying chronic conditions.
- Address malnutrition.
- Exclusive breastfeeding for infants.
Patient education
- Explain pneumonia diagnosis.
- Importance of completing the full course of antibiotics.
- Need for rest and adequate fluid intake.
- Symptom relief measures (paracetamol).
- Smoking cessation advice.
- Recognizing signs of worsening or complications requiring return.
- Importance of vaccinations for future prevention.
Uganda-specific notes
High burden, especially in children and PLHIV. Diagnosis often clinical based on WHO IMCI/adult guidelines. Amoxicillin is first-line oral agent. Benzylpenicillin/Ampicillin + Gentamicin common inpatient regimen. Consider TB co-infection. PCP common OI in HIV.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 5, Section 5.2.9 (and subsections for age groups)
- IMCI Guidelines (for children)
(Referenced implicitly for child pneumonia classification/management)