Title Acute Bronchitis and Pneumonia.pdf ✅

Version: 11 June 2024 National Antibiotic Guideline, 4th Edition (2024) Clinical Pathways for Primary Care: Acute Bronchitis and Pneumonia Yes No Yes Yes No No Treat as Pneumonia Do CXR as baseline (if facility available) Yes Do CXR (if facility available) (if not available, to refer) Does it suggest pneumonia? No Recommended dosage (adults outpatient) Antibiotics Dosing Duration Remarks Amoxycillin 500-1000mg PO q8h 5-7 days Preferred Amoxycillin / Clavulanate 625mg PO q8h 5-7 days Alternative Doxycycline 100mg PO q12h 5-7 days Alternative 1. The WHO AWaRe (Access, Watch, Reserve) antibiotic book 2022. 2. Pneumonia (community-acquired): antimicrobial prescribing. NICE guideline Sept 2019. Acute Bronchitis likely: - Antibiotics are not needed - Great majority of cases are self-limiting and of viral origin - Symptomatic treatment - Consider bronchodilator in case of wheezing - Consider Influenza during outbreak: - acute fever and myalgia - Oseltamivir 75mg PO q12h for 5 days indicated for high risk* patients (regardless of onset of symptom duration) - for non-high-risk patients, clinical benefit is greatest if initiated within 48 hours *Patients at higher risk for influenza: - Age <2 years or ≥65 years old - Pregnant women or immunosuppressed individuals - Patients with chronic medical conditions e.g. CCF, IHD, chronic lung disease, asthma, CKD, DM, malignancy, chronic liver disease, etc. - Morbid obesity (BMI ≥40 kg/m2) Consider Pertussis during outbreak: - cough ≥ 2weeks - paroxysms of cough - post-tussive vomiting - inspiratory whoop Erythromycin Ethylsuccinate 800mg PO q12h for 14 days Consider COVID-19 CRB-65 (consider hospitalization if ≥2) - Confusion (new onset) - RR ≥ 30 breaths/min - SBP < 90 or DBP ≤ 60mmHg - Age ≥ 65 years old Other consideration for hospitalization: Spo2 < 95%, comorbidities and inability to maintain oral intake Suspected pneumonia / acute bronchitis (ADULTS) acute cough ± sputum Consider differential diagnosis: e.g. URTI, asthma, COPD, CCF, post nasal drip, ACE-I induced cough Vital Sign Abnormalities – if any of the following: Tachycardia (HR > 100 beats/min) Tachypnoea (RR > 24 breaths/min) Fever (Temperature > 380C) Hypoxemia (SPO2 <95%) Physical Examination: Abnormalities suggestive of consolidation or pleural effusion? Physical Examination: Abnormalities suggestive of consolidation or pleural effusion?
Version: 11 June 2024 National Antibiotic Guideline, 4th Edition (2024) Clinical Pathways for Primary Care: Acute Bronchitis and Pneumonia Community Acquired Pneumonia (CHILDREN) Clinical presentation • New onset (<2 weeks) or worsening cough with fever (≥38.0 °C), dyspnoea, tachypnoea, reduced oxygen saturation, crepitations, cyanosis, grunting, nasal flaring, pallor • Pneumonia is diagnosed on: fast breathing for age and/or chest indrawing • Check for hypoxia with pulse oximeter if available • Children with runny nose and cough and no signs of severity usually do not have pneumonia and should not receive an antibiotic, only home care advice Assessment of Severity • The predictive value of respiratory rate for the diagnosis of pneumonia may be improved by making it age specific. • Tachypnoea is defined as follows: o < 2 months age: > 60 /min o 2 to 12 months age: > 50 /min o 12 months to 5 years age: > 40 /min • For the normal value of respiratory rate and heart rate according to age group, refer to Paediatric Protocol Investigation • Children with bacterial pneumonia cannot be reliably distinguished from those with viral disease on the basis of any single parameter: Clinical, laboratory or chest X-ray findings • Chest radiograph: Not always necessary if facilities are not available or if pneumonia is mild • White blood cell count o Increased counts with predominance of polymorphonuclear cells suggest bacterial cause o Leucopenia suggests either a viral cause or severe overwhelming infection • Tests for COVID-19 and influenza can be considered if clinically indicated and available Criteria for hospitalization • Children aged 3 months and below, whatever the severity of pneumonia • Fever (more than 38.50C) • Refusal to feed and vomiting • Fast breathing (refer to Assessment of Severity section) with or without cyanosis • Associated systemic manifestation e.g. convulsion, lethargic or reduced level of consciousness • Failure of previous antibiotic therapy • Recurrent pneumonia • Severe underlying disorder e.g. immunodeficiency
Version: 11 June 2024 National Antibiotic Guideline, 4th Edition (2024) Clinical Pathways for Primary Care: Acute Bronchitis and Pneumonia Treatment Outpatient management • In children with mild pneumonia, their breathing is fast but there is no chest indrawing • Oral antibiotics can be prescribed • Educate parents/caregivers about management of fever, preventing dehydration and identifying signs of deterioration • The child should return in 2-days for reassessment or earlier if the condition is getting worse Recommended dosage (children outpatient) Antibiotics Dosing Duration Remarks Amoxicillin 80-90mg/kg/day PO q12h (max 4gm/day) Oral weight bands 3 to <6kg : 250 mg q12h 6 to <10kg : 375 mg q12h 10 to <15kg : 500 mg q12h 15 to <20kg : 750 mg q12h >20kg : 500mg q8h or 1g q12h 5-7 days Preferred Erythromycin Ethylsuccinate* 30-50mg/kg/day PO q12h (max 2gm/day) 5-7 days Alternative *Macrolide antibiotics should be used if either mycoplasma or chlamydia pneumonia is suspected. It may be started in school-going children where disease predominates. 1. The WHO AWaRe (Access, Watch, Reserve) antibiotic book 2022. 2. Paediatric Protocols for Malaysian Hospitals 4th Edition, 2018.