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Lower respiratory tract infection: which antibiotics should be given?

irina mazovka/dreamstime.comA 20-month-old boy presents with fever and difficulty breathing that started in the morning. He has had a minor cold for the past two days. He has reduced breath sounds, but equal inspiratory and expiratory phases. He has no pallor or signs of dehydration, and is eating normally. There is no previous medical history of note and vaccinations are up to date. The following are noted on examination:

  • Respiratory rate 35 breaths per minute (normal 25– 35bpm)
  • Heart rate 95 beats per minute (normal 110–160bpm)
  • Blood pressure 100/55mmHg (normal systolic blood pressure 80–95mmHg)
  • Temperature 38C (normal 36–37C)

Should this child with mild symptoms of lower respiratory tract infection be prescribed antibacterial treatment? According to the summary of antibacterial therapy (Table 1, section 5.1, BNFC 2012-2013), children under two years of age with mild symptoms of lower respiratory tract infection (particularly those vaccinated with pneumococcal polysaccharide conjugate vaccine and haemophilus type b conjugate vaccine, as this 20-month-old would be) are unlikely to have pneumonia. Antibacterial treatment may be considered if symptoms persist.

The child is prescribed paracetamol suspension and his parents are advised to keep him hydrated and to bring him back to surgery if his symptoms persist or worsen.

Two days later he has a cough, still has difficulty breathing, and is more lethargic. Despite receiving regular paracetamol, he remains febrile. He has decreased breathing sounds and bilateral expiratory wheezing. There is no pallor or signs of dehydration. Although he is eating at his usual times, he is not finishing his food. This time, the following vital signs are noted:

  • Respiratory rate 45bpm
  • Heart rate 100bpm
  • Blood pressure 95/55mmHg
  • Temperature 38.7C

You suspect that this child has bacterial community-acquired pneumonia. Which antibacterial therapy should be prescribed? Oral amoxicillin is the treatment of choice for this child who has no risk factors for staphylococcal infection (eg, no recent history of influenza or measles, which can lead to this complication). Clarithromycin can be added if there is no response to amoxicillin. The suggested duration of treatment is seven days.

The child’s parents report that they experienced a flu-like illness a week before he became unwell. How might this change your choice of antibacterial therapy? Staphylococcus aureus is an important cause of bacterial pneumonia following influenza. Many strains of S aureus produce a ?-lactamase that confers resistance to amoxicillin. The recommended treatment in this situation is co-amoxiclav alone or amoxicillin plus flucloxacillin.

Key points

  • Oral amoxicillin is the treatment of choice for bacterial community-acquired pneumonia in children with no risk factors for staphylococcal infection.
  • Staphylococcal pneumonia is a complication that can follow influenza or measles.
  • Many strains of S aureus produce ß-lactamase so the recommended treatment in staphylococcal pneumonia is co-amoxiclav alone or amoxicillin plus flucloxacillin.


Should the boy be prescribed oseltamivir? According to the summary of National Institute for Health and Clinical Excellence guidance (section 5.3.4 , BNFC 2012–2013), oseltamivir is recommended for the treatment of influenza in at-risk children who can start treatment within 48 hours of the onset of symptoms, when influenza is circulating in the community. A list of conditions that define a child as at risk is published in BNFC and includes:

  • Chronic respiratory disease
  • Chronic heart disease
  • Chronic renal disease
  • Chronic liver disease
  • Chronic neurological disease
  • Immunosuppression
  • Diabetes mellitus

This child is not in the at-risk category and his influenza-like illness has been present for more than two days so he should not receive the antiviral. (Note, however, that for patients with severe influenza or for those who are immunocompromised, oseltamivir may still be effective after this time if viral shedding continues [unlicensed use].)

When can intravenous antibacterial therapy be considered?
Even severe uncomplicated community-acquired pneumonia can usually be treated successfully with oral antibiotics. Intravenous antibacterial therapy should be used if the child develops septicaemia or complicated pneumonia, or if oral administration is not possible.

Based on a case study from the BNF/BNFC e-newsletter, July 2012, available at /org_450066.htm

Citation: The Pharmaceutical Journal URI: 11108029

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