Syahmi Mubasyir, one year old boy, experienced sudden onset of fast breathing at

10:30 PM before he was admitted to Sibu Hospital on 30 th October 2014. Based on

the history of presenting illness, he presented to A&E department with lower
respiratory tract symptoms and he is likely to have lower respiratory infection which
is caused by bacterial pneumonia. Pneumonia is an inflammation of lung
parenchyma (alveoli). Its aetiology can be either infection or non-infection. For
infection, it can be caused by either virus or bacteria, for immunosuppressed
patient, it can be cause by fungi and non-infectious include aspiration of food or
gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity
reactions and drug or radiation.
In the context of Syahmi Mubasyir, his pneumonia is likely due to infection from
bacteria because he having high grade fever. Though, viral pneumonia is common
at his age but bacterial pneumonia cannot be excluded because he had past history
of bronchiolitis on September 2014. As we all know, the commonest aetiology of
bronchiolitis for his age is respiratory syncytial virus (RSV). This infection from RSV
predisposes him to secondary bacterial infection by disturbing host defense
mechanisms, altering secretions and modifying the bacterial flora of respiratory
tract. Thus, make him susceptible to bacterial infection. Therefore, he is likely to
developed bacterial pneumonia rather than viral pneumonia because he is
completely recovered from bronchiolitis before. Table below shows the likely
bacterial pathogens according to the age of the patient:
Age
Newborns
Infants 1 3 months
Preschool age
School age

Bacterial Pathogen
Group B Streptcoccus, Escherichia coli, Kleibsiella sp.,
Enterobacteriaceae
Chlamydia trachomatis
Streptococcus pneumoniae, Haemophilus influenza type
b, Staphylococcal aureus
Mycoplasma pneumoniae, Chlamydia pneumoniae

Viral and bacterial pneumonias are often preceded several days of symptoms of
upper respiratory tract infection, typically rhinitis and cough. Syahmi Mubasyir
experienced these symptoms before. In pneumonia, tachypnea is the most
consistent clinical manifestation. With that, it is often accompanied by increased
work of breathing such as intercostals, subcostal and suprasternal retractions, nasal
flaring and use of accessory muscles. On auscultation of the chest, it may reveal
crepitations and rhonci. However, these clinical manifestations could not
differentiate between viral and bacterial pneumonia. Generally, in viral pneumonia
the temperature is lower than in bacterial pneumonia. However, this needs to be
confirmed with several investigations.
There are several investigations that should be done in order to support the
diagnosis of pneumonia. Firstly, chest radiography, an infiltrate on chest

radiography supports the diagnosis of pneumonia. Viral pneumonia is usually

characterized by hyperinflation with bilateral interstitial infiltrates and peribronchial
cuffing. Confluent lobar consolidation is typically seen with pneumococcal
pneumonia. Chest radiography also would show complications of pneumonia such
as empyema and tension pneumothorax.
Second investigation that should be done is full blood count. Usually, peripheral
white blood cell count will elevated with pneumonia and it is also a useful
investigation in differentiating viral form bacterial pneumonia. In viral pneumonia,
the white blood cells count can be normal or elevated but is usually not higher than
20,000/mm3 with lymphocytes predominance. However, bacterial pneumonia is
often associated with an elevation of white blood cell count, in the range of 15,00040,000/mm3 with predominance of granulocytes. After that, blood culture and
antibiotic sensitivity should be done in order to commencing appropriate antibiotic
therapy to this patient.
Besides that, several other investigations should be done in order to assess other
complications of pneumonia which can be fatal to this patient such as dehydration
and hypercapnia which could lead to metabolic acidosis. Two important
investigations should be done to assess these, first, blood urea serum electrolytes
test. This investigation carried out to identify which ions is deficient more, then, the
correction could be made. Second, oximetry. This is done to assess oxygen
saturation in the patient. If the oxygen saturation is low, the patient might enter
anaerobic respiration phase, and more production of lactic acid. This excessive
production of lactic acid cause enzymes to be denatured and a lot of metabolic
processes to be halted and the patient may die due to this. Therefore, oxygen
saturation could be corrected by this procedure of monitoring.
As we knew the aetiology of the pneumonia, we need to treat it by eradicating the
aetiological pathogen by antibiotic therapy as well as start the patient with
supportive therapy, such as:

Fluids
Oxygen
Cough medication
Temperature control
Chest physiotherapy

However, this antibiotic therapy should be withhold if the aetiological pathogen is

virus because virus infection is usually self limiting and heal with time. Patient with
viral pneumonia should be treated with supportive therapy. If the illness becomes
severe, there may be co-infection with bacteria. So, this patient needs to be start
with antibiotic therapy. Below is list of antibiotics for corresponding bacterias :
Bacterial pathogens and Recommended antimicrobial agents
Pathogen
Antimicrobial agent

Beta-lactam susceptible
Streptococcus pneumonia
Haemophilus influenzae type b
Staphylococcus aureus
Group A Streptococcus
Mycoplasma pneumoniae
Chlamydia pneumoniae
Bordetella pertussis

Penicillin, cephalosporins
Ampicillin,
chloramphenicol,
cephalosporins
Cloxacillin
Penicillin, cephalosporin
Macrolides,
e.g.
erythromycin,
azithromyci
Macrolides,
e.g.
erythromycin,
azithromyci
Macrolides,
e.g.
erythromycin,
azithromyci