management of community acquired pneumonia in infants and children older than 3 months of age daniel...
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Management of Community Management of Community Acquired Pneumonia in Acquired Pneumonia in
Infants and Children Older Infants and Children Older than 3 Months of Age than 3 Months of Age
Daniel Urschel, MD, Charles Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MDPace, MD, Sherman Alter, MDDepartment of Pediatrics, Department of Pediatrics, Boonshoft School of Medicine, Boonshoft School of Medicine, Wright State University, The Wright State University, The Children’s Medical Center of Children’s Medical Center of DaytonDayton
ObjectivesObjectives
1. List common pathogens causing community-acquired pneumonia (CAP) in infants and children.
2. Discuss appropriate use of diagnostic laboratory and imaging tests in a child with CAP in an outpatient or inpatient setting.
3. Review choice of anti-infective therapy and duration of treatment provided to a child with suspected CAP in the outpatient or inpatient setting.
“Teasers are docile male horses, usually old and past prime with undesirable genes, who set up aggressive just off-the-track mares to be bred by the wild testosterone crazed prize stallions whose only job is to deliver the goods, which they do. “
A 3yr old female presents to your office in A 3yr old female presents to your office in November with cough and tachypnea. You hear November with cough and tachypnea. You hear
crackles in left lower lobe and minimal crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good retractions. She is alert, talkative, has had good
fluid intake. Previously healthy and fluid intake. Previously healthy and immunizations up to date. You believe patient immunizations up to date. You believe patient
may be well enough to manage as an outpatient. may be well enough to manage as an outpatient. Which diagnostic tests should be performed on Which diagnostic tests should be performed on
this patient?this patient?
1 2 3 4 5
0%
33% 33%
0%
33%
1.1. Complete blood countComplete blood count
2.2. Chest radiographChest radiograph
3.3. Pulse oximetryPulse oximetry
4.4. Blood cultureBlood culture
5.5. All of the aboveAll of the above
A 3yr old female presents to your office in A 3yr old female presents to your office in November with cough and tachypnea. You hear November with cough and tachypnea. You hear
crackles in left lower lobe and minimal crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good retractions. She is alert, talkative, has had good
fluid intake. Previously healthy and fluid intake. Previously healthy and immunizations up to date. You believe patient immunizations up to date. You believe patient
may be well enough to manage as an outpatient. may be well enough to manage as an outpatient. Which diagnostic tests should be performed on Which diagnostic tests should be performed on
this patient?this patient?
1 2 3 4 5
0%
33% 33%
0%
33%
1.1. Complete blood countComplete blood count
2.2. Chest radiographChest radiograph
3.3. Pulse oximetryPulse oximetry
4.4. Blood cultureBlood culture
5.5. All of the aboveAll of the above
A school aged child hospitalized with A school aged child hospitalized with community-acquired pneumonia can be safely community-acquired pneumonia can be safely discharged if he meets which of the following discharged if he meets which of the following
criteria?criteria?
1 2 3 4 5
33%
67%
0%0%0%
1.1. Able to tolerate Able to tolerate outpatient meds, outpatient meds, greater level of activity, greater level of activity, improving appetite. improving appetite.
2.2. Afebrile for over 24 Afebrile for over 24 hourshours
3.3. Pulse oximetry Pulse oximetry measurements >90% in measurements >90% in room air at least 12 room air at least 12 hourshours
4.4. A and CA and C
5.5. A, B, and CA, B, and C
Previously healthy 2 yr old diagnosed with pneumonia Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. (faint crackles in the right base) in late October.
Respiratory rate is 30 breaths/minute and Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all temperature is 38.5° C. She has received all
recommended immunizations. She attends a day care recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided Which oral anti-infective therapy should be provided
to this child managed as an outpatient?to this child managed as an outpatient?
1 2 3 4 5
33%
0% 0%
33%33%
1.1. A second-or third-generation A second-or third-generation cephalosporin (e.g., cefdinir, cephalosporin (e.g., cefdinir, cefixime) for 10 days.cefixime) for 10 days.
2.2. Amoxicillin 90mg/kg/day Amoxicillin 90mg/kg/day divided 2 times a day for 10 divided 2 times a day for 10 daysdays
3.3. Azithromycin 10 mg/kg on Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5day 1, 5 mg/kg on days 2-5
4.4. Combined treatment with Combined treatment with both amoxicilln and both amoxicilln and azithromycin as noted aboveazithromycin as noted above
5.5. No anti-infective therapy No anti-infective therapy indicatedindicated
A fully-immunized 6 yr old boy is hospitalized at A fully-immunized 6 yr old boy is hospitalized at Dayton Children’s. Radiography demonstrates left Dayton Children’s. Radiography demonstrates left lower lobe consolidation without an effusion. He lower lobe consolidation without an effusion. He
has a 92% SpO2 on 30% FiO2, some retractions and has a 92% SpO2 on 30% FiO2, some retractions and poor oral fluid intake. A blood culture is obtained. poor oral fluid intake. A blood culture is obtained. What first-line antibiotic therapy is recommended?What first-line antibiotic therapy is recommended?
1 2 3 4 5
0%
33%
0%0%
67%
1.1. A third-generation A third-generation parenteral cephalosporin parenteral cephalosporin (e.g., cefotaxime or (e.g., cefotaxime or ceftriaxone)ceftriaxone)
2.2. Intravenous clindamycinIntravenous clindamycin
3.3. A third-generation A third-generation parenteral cephalosporin parenteral cephalosporin plusplus azithromycin azithromycin
4.4. Intravenous ampicillinIntravenous ampicillin
5.5. Intravenous vancomycinIntravenous vancomycin
A 5 yr old is admitted with a right upper lobe A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His pneumonia. Child is not fully immunized. His
blood cultures yield Streptococcus pneumoniae. blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate Susceptibility testing on the blood isolate
demonstrates a penicillin MIC of > 4 ug/mL. demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this Appropriate antibiotic therapy directed at this
pathogen consists of:pathogen consists of:
1 2 3 4 5
0%
100%
0%0%0%
1.1. Ceftriaxone Ceftriaxone intravenously at intravenously at 100mg/kg/day100mg/kg/day
2.2. Levofloxacin Levofloxacin intravenously at 20 intravenously at 20 mg/kg/daymg/kg/day
3.3. Ampicillin intravenously Ampicillin intravenously at 400 mg/kg/dayat 400 mg/kg/day
4.4. A or CA or C
5.5. A, B, or CA, B, or C
IntroductionIntroduction
The Pediatric Infectious Diseases Society The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of (PIDS) and the Infectious Diseases Society of America (IDSA) convened multiple America (IDSA) convened multiple subspecialists and expert consultants to subspecialists and expert consultants to create and review guidelinescreate and review guidelines
Guidelines endorsed by AAP, American Guidelines endorsed by AAP, American College of Emergency Physicians, Society of College of Emergency Physicians, Society of Critical Care Medicine….Critical Care Medicine….
The guidelines grade method of The guidelines grade method of recommendation, low or very low evidence recommendation, low or very low evidence situations require clinical judgmentsituations require clinical judgment
Inpatient CriteriaInpatient Criteria
Age 3-6 months with a suspicion of Age 3-6 months with a suspicion of bacterial pneumoniabacterial pneumonia
Suspicion or documentation of Suspicion or documentation of methicillin-resistant methicillin-resistant Staphylococcus Staphylococcus aureus aureus (MRSA) pneumonia(MRSA) pneumonia
Concern for follow up or Concern for follow up or administration of home therapyadministration of home therapy
Outpatient DiagnosticsOutpatient Diagnostics
Chest radiography, blood culture, CBC, Chest radiography, blood culture, CBC, ESR/CRP ESR/CRP not necessarynot necessary
Pulse oximetry should be obtained in all Pulse oximetry should be obtained in all patients patients
If available a rapid test for influenza and for If available a rapid test for influenza and for other viral pathogens should be obtainedother viral pathogens should be obtained
Testing for Testing for Mycoplasma pneumoniae Mycoplasma pneumoniae should should be obtained if suspiciousbe obtained if suspicious
If no improvement on antibiotics for 48-72 hrs, If no improvement on antibiotics for 48-72 hrs, a CXR and blood culture should be obtaineda CXR and blood culture should be obtained
Inpatient WorkupInpatient Workup All pt’s should have CXR All pt’s should have CXR Blood cultureBlood culture CBCCBC ESR/CRPESR/CRP Urinary antigen for Pneumococcal infection is Urinary antigen for Pneumococcal infection is
not recommendednot recommended Sputum samples if able (weak; low evidence)Sputum samples if able (weak; low evidence) Rapid tests for Influenza and viruses should be Rapid tests for Influenza and viruses should be
usedused Mycoplasma pneumoniae Mycoplasma pneumoniae should be tested for should be tested for
if suspiciousif suspicious No reliable test for No reliable test for Chlamydophila pneumoniaeChlamydophila pneumoniae
Inpatient DiagnosticsInpatient Diagnostics
A routine repeat CXR is not necessaryA routine repeat CXR is not necessary Repeat CXR should be obtained if no clinical Repeat CXR should be obtained if no clinical
improvement is demonstrated by 48-72 hrsimprovement is demonstrated by 48-72 hrs If blood culture yields MRSA, a repeat culture If blood culture yields MRSA, a repeat culture
is mandatory todocument sterility of the blood.is mandatory todocument sterility of the blood. If blood culture is positive for another If blood culture is positive for another
organism, repeat culture of blood is not organism, repeat culture of blood is not mandatorymandatory
Tracheal aspirate should be obtained in patient Tracheal aspirate should be obtained in patient with endotracheal intubationwith endotracheal intubation
Criteria for admission to Criteria for admission to an ICUan ICU
Intubation, continuous CPAP or Intubation, continuous CPAP or BIPAPBIPAP
Sustained tachycardia or Sustained tachycardia or hypotensionhypotension
<92% SpO2 on >50% FiO2<92% SpO2 on >50% FiO2 Altered mental statusAltered mental status Clinical judgment should be used Clinical judgment should be used
regardless of scoresregardless of scores
Discharge CriteriaDischarge Criteria
Improved Clinical Status >12 hrsImproved Clinical Status >12 hrs RA with Sp02 >90% >12 hrs RA with Sp02 >90% >12 hrs No increased work of breathing , No increased work of breathing ,
tachypnea or tachycardiatachypnea or tachycardia Able to tolerate outpatient therapy Able to tolerate outpatient therapy Chest tube out for >12 hrs Chest tube out for >12 hrs
Antibiotics not routinely required for Antibiotics not routinely required for preschool-aged childrenpreschool-aged children
High-dose amoxicillin should be considered High-dose amoxicillin should be considered first line for presumed bacterial pneumonia first line for presumed bacterial pneumonia in all agesin all ages 90 mg/kg/day divided bid90 mg/kg/day divided bid TID dosing is required for Pen-resistant TID dosing is required for Pen-resistant
pneumococcus (MIC > 2 µg/mL)pneumococcus (MIC > 2 µg/mL) Macrolides (azithromycin) should be Macrolides (azithromycin) should be
considered in school-aged and adolescents considered in school-aged and adolescents with illness consistent with atypical with illness consistent with atypical pneumoniapneumonia
Outpatient Treatment of Outpatient Treatment of PneumoniaPneumonia
Atypical Atypical vs. Bacterialvs. Bacterial
Gradual onsetGradual onset Malaise, headache, Malaise, headache,
sore throat, ear sore throat, ear infectionsinfections
Lower fevers (101-Lower fevers (101-102)102)
Usually Usually nonproductive, nonproductive, persistent coughpersistent cough
May or may not have May or may not have ralesrales
Gradual or acute Gradual or acute onsetonset
Fatigue, dyspnea, Fatigue, dyspnea, chest painchest pain
Fevers often higher Fevers often higher (>103)(>103)
Cough more often Cough more often productiveproductive
Decreased or bronchial Decreased or bronchial breath sounds, rales, breath sounds, rales, dullness to percussion, dullness to percussion, egophonyegophony
Outpatient Treatment of Outpatient Treatment of PneumoniaPneumonia
For presumed atypical pneumonia, For presumed atypical pneumonia, azithromycin is first-lineazithromycin is first-line 10 mg/kg on day 1; 5 mg/kg on days 2-510 mg/kg on day 1; 5 mg/kg on days 2-5
In season, treat influenza presumptively In season, treat influenza presumptively until a sensitive test is negativeuntil a sensitive test is negative
10-day course of antibiotics is usually 10-day course of antibiotics is usually adequateadequate Azithromycin: 5 day courseAzithromycin: 5 day course MRSA will require a longer course (and MRSA will require a longer course (and
hospitalization!)hospitalization!)
Inpatient Treatment of Inpatient Treatment of PneumoniaPneumonia
For the fully immunized child in regions For the fully immunized child in regions that do not demonstrate high-level that do not demonstrate high-level pneumococcal penicillin resistance:pneumococcal penicillin resistance: Ampicillin or Penicillin G are first-lineAmpicillin or Penicillin G are first-line Azithromycin for suspected atypical Azithromycin for suspected atypical
pneumonia (with a beta-lactam if diagnosis pneumonia (with a beta-lactam if diagnosis is in question)is in question)
Vancomycin or clindamycin should be Vancomycin or clindamycin should be added when added when S. aureus S. aureus is suspected by labs, is suspected by labs, clinical findings or imagingclinical findings or imaging
Ceftriaxone or cefotaxime are alternativesCeftriaxone or cefotaxime are alternatives
Inpatient Treatment of Inpatient Treatment of PneumoniaPneumonia
For a not fully immunized child or in For a not fully immunized child or in regions that demonstrate high-level regions that demonstrate high-level pneumococcal penicillin resistance:pneumococcal penicillin resistance: Ceftriaxone or cefotaxime is preferredCeftriaxone or cefotaxime is preferred Add azithromycin if considering atypical Add azithromycin if considering atypical
pneumoniapneumonia Add vancomycin or clindamycin for Add vancomycin or clindamycin for S. aureusS. aureus
Ceftriaxone or cefotaxime also preferred Ceftriaxone or cefotaxime also preferred for life-threatening infections and for life-threatening infections and empyemaempyema
Pneumococcal Penicillin Pneumococcal Penicillin ResistanceResistance
MIC < 0.06 µg/mL: MIC < 0.06 µg/mL: very susceptiblevery susceptible Standard-dose oral amoxicillin effectiveStandard-dose oral amoxicillin effective
MIC 0.12-1 µg/mL: MIC 0.12-1 µg/mL: susceptiblesusceptible High-dose oral amoxicillin effectiveHigh-dose oral amoxicillin effective
MIC 1-2: MIC 1-2: somewhat resistantsomewhat resistant High-dose oral amoxicillin >90% effectiveHigh-dose oral amoxicillin >90% effective
MIC 2-4: MIC 2-4: resistantresistant Oral therapy likely to fail; IV ampicillin or penicillinOral therapy likely to fail; IV ampicillin or penicillin
MIC >4: MIC >4: very resistantvery resistant Standard-dose ampicillin likely to fail; ceftriaxone Standard-dose ampicillin likely to fail; ceftriaxone
effectiveeffective
Viral Pneumonia in Viral Pneumonia in ChildrenChildren
Guidelines suggest not treating a preschool-Guidelines suggest not treating a preschool-aged child with suspected viral pneumonia aged child with suspected viral pneumonia (except influenza)(except influenza)
Hamano-Hasegawa, Hamano-Hasegawa, J Infect ChemotherJ Infect Chemother (2008) (2008) Younger children more likely to have viral pneumoniaYounger children more likely to have viral pneumonia Evidence of bacterial co-infection in Evidence of bacterial co-infection in 33%33%
Michelow, Michelow, PediatricsPediatrics (2004) (2004) Bacterial co-infections seen in Bacterial co-infections seen in 54%54% of viral of viral
pneumoniaspneumonias 67% of influenza pneumonia67% of influenza pneumonia 55% of RSV pneumonia55% of RSV pneumonia
Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.
Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.
Viral Pneumonia in Viral Pneumonia in ChildrenChildren
A 2010 retrospective cohort study of 4015 A 2010 retrospective cohort study of 4015 pediatric patients hospitalized with pediatric patients hospitalized with pneumoniapneumonia 27% developed influenza-associated 27% developed influenza-associated
pneumoniapneumonia Of these, 2% had a bacterial co-infectionOf these, 2% had a bacterial co-infection 18 identified by blood cultures; 3 by pleural 18 identified by blood cultures; 3 by pleural
fluidfluid The actual incidence of secondary bacterial The actual incidence of secondary bacterial
pneumonia with influenza is likely much pneumonia with influenza is likely much higherhigherDagwood FS et al. “Influenza-Associated Pneumonia in Children Hospitalized
With Laboratory-Confirmed Influenza, 2003-2008.” Pediatr Infect Dis J. 2010 Jul;29(7):585-90.
Adjunctive TherapyAdjunctive Therapy
CXR should be obtained if suspicious CXR should be obtained if suspicious for effusionfor effusion
US or CT if CXR is inconclusiveUS or CT if CXR is inconclusive Size of effusion and respiratory Size of effusion and respiratory
compromise will determine compromise will determine treatmenttreatment
Pleural Fluid TestsPleural Fluid Tests
Gram stain (+25-50%)Gram stain (+25-50%) Antigen or PCR if available (Antigen or PCR if available (S. S.
pneumoniaepneumoniae, , S.aureusS.aureus)) Pleural fluid analysis rarely changes Pleural fluid analysis rarely changes
management and is not recommendedmanagement and is not recommended WBC count with differntial helps WBC count with differntial helps
differentiate sourcedifferentiate source Majority of cultures will be negativeMajority of cultures will be negative
Effusion/EmpyemaEffusion/Empyema
Total antibiotic therapy 2-4 weeks or 10 days Total antibiotic therapy 2-4 weeks or 10 days after resolution of feverafter resolution of fever
If abscess or necrosis is identified tx should If abscess or necrosis is identified tx should begin with IV antibioticsbegin with IV antibiotics
If abscess is peripheral may attempt to drain, If abscess is peripheral may attempt to drain, most will resolve spontaneously with IV most will resolve spontaneously with IV antibioticsantibiotics
Abscess secondary to congenital malformation Abscess secondary to congenital malformation requires surgery consultationrequires surgery consultation
Necrosis should not routinely be managed Necrosis should not routinely be managed surgically given high rates of broncho-pleural surgically given high rates of broncho-pleural fistulasfistulas
A 3yr old female presents to your office in A 3yr old female presents to your office in November with cough and tachypnea. You hear November with cough and tachypnea. You hear
crackles in left lower lobe and minimal crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good retractions. She is alert, talkative, has had good
fluid intake. Previously healthy and fluid intake. Previously healthy and immunizations up to date. You believe patient immunizations up to date. You believe patient
may be well enough to manage as an outpatient. may be well enough to manage as an outpatient. Which diagnostic tests should be performed on Which diagnostic tests should be performed on
this patient?this patient?
1 2 3 4 5
0%
33% 33%
0%
33%
1.1. Complete blood countComplete blood count
2.2. Chest radiographChest radiograph
3.3. Pulse oximetryPulse oximetry
4.4. Blood cultureBlood culture
5.5. All of the aboveAll of the above
A school aged child hospitalized with A school aged child hospitalized with community-acquired pneumonia can be safely community-acquired pneumonia can be safely discharged if he meets which of the following discharged if he meets which of the following
criteria?criteria?
1 2 3 4 5
0% 0% 0%0%
100%1.1. Able to tolerate Able to tolerate outpatient meds, outpatient meds, greater level of activity, greater level of activity, improving appetite. improving appetite.
2.2. Afebrile for over 24 Afebrile for over 24 hourshours
3.3. Pulse oximetry Pulse oximetry measurements >90% in measurements >90% in room air at least 12 room air at least 12 hourshours
4.4. A and CA and C
5.5. A, B, and CA, B, and C
Previously healthy 2 yr old diagnosed with pneumonia Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. (faint crackles in the right base) in late October.
Respiratory rate is 30 breaths/minute and Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all temperature is 38.5° C. She has received all
recommended immunizations. She attends a day care recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided Which oral anti-infective therapy should be provided
to this child managed as an outpatient?to this child managed as an outpatient?
1 2 3 4 5
0%
67%
33%
0%0%
1.1. A second-or third-generation A second-or third-generation cephalosporin (e.g., cefdinir, cephalosporin (e.g., cefdinir, cefixime) for 10 days.cefixime) for 10 days.
2.2. Amoxicillin 90mg/kg/day Amoxicillin 90mg/kg/day divided 2 times a day for 10 divided 2 times a day for 10 daysdays
3.3. Azithromycin 10 mg/kg on Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5day 1, 5 mg/kg on days 2-5
4.4. Combined treatment with Combined treatment with both amoxicilln and both amoxicilln and azithromycin as noted aboveazithromycin as noted above
5.5. No anti-infective therapy No anti-infective therapy indicatedindicated
Previously healthy 2 yr old diagnosed with pneumonia Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. (faint crackles in the right base) in late October.
Respiratory rate is 30 breaths/minute and Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all temperature is 38.5° C. She has received all
recommended immunizations. She attends a day care recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided Which oral anti-infective therapy should be provided
to this child managed as an outpatient?to this child managed as an outpatient?
1 2 3 4 5
0% 0% 0%
33%
67%
1.1. A second-or third-generation A second-or third-generation cephalosporin (e.g., cefdinir, cephalosporin (e.g., cefdinir, cefixime) for 10 days.cefixime) for 10 days.
2.2. Amoxicillin 90mg/kg/day Amoxicillin 90mg/kg/day divided 2 times a day for 10 divided 2 times a day for 10 daysdays
3.3. Azithromycin 10 mg/kg on Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5day 1, 5 mg/kg on days 2-5
4.4. Combined treatment with Combined treatment with both amoxicilln and both amoxicilln and azithromycin as noted aboveazithromycin as noted above
5.5. No anti-infective therapy No anti-infective therapy indicatedindicated
A 5 yr old is admitted with a right upper lobe A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His pneumonia. Child is not fully immunized. His
blood cultures yield Streptococcus pneumoniae. blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate Susceptibility testing on the blood isolate
demonstrates a penicillin MIC of > 4 ug/mL. demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this Appropriate antibiotic therapy directed at this
pathogen consists of:pathogen consists of:
1 2 3 4 5
0%
33%
0%
33%33%
1.1. Ceftriaxone Ceftriaxone intravenously at intravenously at 100mg/kg/day100mg/kg/day
2.2. Levofloxacin Levofloxacin intravenously at 20 intravenously at 20 mg/kg/daymg/kg/day
3.3. Ampicillin intravenously Ampicillin intravenously at 400 mg/kg/dayat 400 mg/kg/day
4.4. A or CA or C
5.5. A, B, or CA, B, or C