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Treatment of pneumonia is often empirically based and

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Treatment of pneumonia is often empirically based and thus, information on antibiotic resistance patterns and mechanismsof resistance is important to determine the most appropriate treatment.For S. pneumoniae, the most common mechanism of resistance topenicillins is alteration of penicillin-binding sites that can be overcome with higher doses of the drug (6).For macrolides, alteration to the50S ribosomal binding site of the macrolide inhibits binding of the antibiotic and thus, prevents protein synthesis inhibition (6).Inaddition, there is also an increase in efflux pumps for macrolides and this property can be overcome by using macrolides that achieve hightissue concentrations at the site of infection (e.g. azithromycin) (6).Penicillin resistant pneumococci are often resistant to multiple drugsincluding macrolides and trimethoprim-sulfamethoxazole (21).Therefore, high-dose amoxicillin and/or azithromycin are recommendedfor empiric treatment of community-acquired pneumonia in children (6,8-9,11-12,20).Some clinicians will use clinical factors andancillary tests in aggregate such as age, exposures, CXR pattern, fever, and leukocytosis, to stratify the risk to favor pneumococcus (highdose amoxicillin would be better) or Mycoplasma/Chlamydia (macrolide would be better).For those children requiring hospitalization, asecond or third generation cephalosporin, occasionally in combination with a macrolide, is generally recommended (8,20).Most treatmentregimens are continued for a total of 7-14 days although this is based on little evidence (4).Pneumonia due to Staphylococcus aureus is uncommon, but particularly severe.S. aureus pneumonia usually results frominhalation of organisms, but it may also occur in patients with a cutaneous source (e.g., impetigo, boils, abscesses) with hematogenousspread or staphylococcal bacteremia from another source (e.g. osteomyelitis, central line infection).If S. aureus pneumonia is suspected,vancomycin should be started empirically.Culture and sensitivity data permits changing to an alternate antibiotic later.Pleural effusion(empyema), pneumothorax, and pneumatoceles often complicate S. aureus pneumonia.Pleural effusions can be classified in several ways.They can be a transudate or an exudate based on their protein content.Asubpulmonic effusion versus an empyema is more clinically relevant.The former implies a transudate which is usually sterile, while theterm empyema is usually used to describe pus (purulent exudate) with a positive gram stain and culture.The overall outcome in children with pneumonia is excellent.The majority of children will recover without complications (11).Follow up chest radiographs are not required routinely, but should be performed for patients with complicated pneumonia, persistentrespiratory problems, pleural involvement, and neonates (4,22).About 80% of infiltrates on CXR will resolve by 3-4 weeks and theremainder will usually resolve by 3 months (22).Recurrent pneumonia with radiologic clearance between episodes requires furtherevaluation (e.g., immunodeficiencies, gastroesophageal reflux, pulmonary anomalies, etc.) (4).

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Nursing, Pediatrics, Physician, John A Burns, Hawaii John A

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