Clinical Practice Guidelines in the Evaluation and Management of Pediatric

Community Acquired Pneumonia

REGINA M. CANONIZADO,MD

Pediatric Pulmonologist

DISEASE BURDEN

150.7m cases in developing countries 95% under 5y/o 13% requiring admission Rudan,2004

828.8 per 100,00 in the Philippines DOH Field Health Svc IS,2006PhP 324.688M total payment claims PHIC 2006

Goal

The guideline is designed to help make decisions concerning the recognition of community acquired pneumonia in the immunocompetent patient aged 3months to 19 years, identification of appropriate and practical diagnostic procedure, and initiation of rational management.

Who shall be considered as having community-acquired pneumonia?

Predictors of community acquired pneumonia in a patient with cough

1. For ages 3 months to 5 years : tachypnea and/or chest indrawing (grade B)

2. For ages 5 to 12 years: fever, tachypnea and crackles (Grade D)

3. Beyond 12 years of age: the presence of the following features (Grade D)

a. fever, tachypnea and tachycardia and;

b. At least one abnormal chest finding of diminished breath sounds, rhonchi, crackles or wheezes

WHO age specific criteria for tachypnea

AGE RR

2-12 mos >50

1-5 years >40

>5 years >30

Who will require admission?

1. A patient who is at moderate to high risk to develop pneumonia –related mortality should be admitted (Grade D)

2. A patient who is at minimal to low risk can be managed on an outpatient basis (Grade D)

Risk Classification for Pneumonia-Related Mortality

Variables PCAP A Minimal Risk

PCAP B Low Risk

PCAP C Moderate Risk

PCAP D High Risk

1. Co-morbid illness None Present Present Present

2. Compliant caregiver Yes Yes No No

3. Ability to follow-up Possible Possible Not possible

Not possible

4. Presence of Dehydration None Mild Moderate Severe

5. Ability to feed Able Able Unable Unable

6. Age >11 mo >11 mo < 11 mo < 11 mo

7. Respiratory rate 2-12 months 1-5 years > 5 years

> 50/min> 40/min> 30/min

> 50/min> 40/min> 30/min

> 60/min> 50/min> 35/min

> 70/min> 50/min> 35/min

8. Signs of respiratory failure

a. Retraction

b. Head Bobbingc. Cyanosisd. Gruntinge. Apneaf. Sensorium

None

None None None None Awake

None

None None None None Awake

Intercostal/Subcostal

Present Present None None Irritable

Supraclavicular/Intercostal/Subcostal Present Present Present Present lethargic./stuporous/comatose

9. Complications (effusion , pneumothorax)

None None Present Present

ACTION PLAN OPD follow-up at the end of treatment

OPD follow-up after 3 days

Admit to regular ward

Admit to a critical care unit Refer to specialist

What diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B being managed in an ambulatory

setting? No diagnostic aids are initially requested for a

patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting (Grade D)

What diagnostic aids are initially requested for a patient classified as

either PCAP C or PCAP D being managed

in a hospital setting? 1. The following should be routinely requested :

a. Chest x-ray PA lateral (Grade B) b. White blood cell count (Grade C) c. Culture and sensitivity of

Blood for PCAP D (Grade D) Pleural fluid (Grade D) Tracheal aspirate upon initial intubation (Grade D)

Blood gas and/or pulse oximetry (Grade D)

2. The following may be requested : Culture and Sensitivity of sputum for older children (Grade D)

3. The following should not be routinely requested :

a. Erythrocyte sedimentation rate(Grade A)

b. C-reactive protein (Grade A)

When is antibiotic recommended?

An antibiotic is recommended1. For a patient classified as either PCAP A or

B and is a. Beyond 2 years of age (Grade B) or b. Having high grade fever without

wheeze (Grade D)

2. For a patient classified as PCAP C and is

a. Beyond 2 years of age (Grade B ) or

b. Having high grade fever without wheeze (grade D) or

c. Having alveolar consolidation in the chest x-ray (Grade B) or

d. Having white blood cell count > 15, 000 (grade C)

3. For a patient classified as PCAP D (Grade D)

FEATURES BACTERIAL VIRAL

Fever T> 38.5o C T< 38.5o C

Wheeze Absent Present

What empiric treatment should be administered if a bacterial etiology is

strongly considered?

1. For a patient classified as PCAP A or B without previous antibiotic, oral amoxicillin ( 40-50 mg/kg/ay in 3 divided doses) is the drug of choice (Grade D)

2. For a patient classified as PCAP C without previous antibiotic and who has completed the primary immunization against Haemophilus influenza type b, Penicillin G (100, 000 units/kg/day in 4 divided doses) is the drug of choice (Grade D)

If a primary immunization against Hib has not been completed, intravenous ampicillin (100 mg/kg/day in 4 divided doses) should be given (Grade D)

3. For a patient classified as PCAP D, a specialist should be consulted (Grade D)

What treatment should be initially given if a viral etiology is strongly

considered?

1. Ancillary treatment should only be given (Grade D)

2. Oseltamivir (2 mg/kg/dose BID for 5 days) or amantadine (4.4-8.8 mg/kg/day for 3-5 days) may be given for influenza that is either confirmed by laboratory (Grade B) or occurring as an outbreak (Grade D)

When can a patient be considered as responding to the current antibiotic?

1. Decrease in respiratory signs (particularly tachypnea ) and defervescence within 72 hours after initiation of antibiotic are predictors of favorable therapeutic response (Grade D)

2. Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation (Grade B)

3. End of treatment chest x-ray (Grade B), WBC, ESR or CRP should not be done to assess therapeutic response to antibiotic (Grade D)

What should be done if a patient is not responding to current antibiotic therapy ?

1. If an outpatient classified either PCAP A and PCAP B is not responding to the current antibiotic within 72 hours, consider any one of the following (Grade D)

a. Change of initial antibiotic; or

b. Start an oral macrolide; or

c. Reevaluate diagnosis

2. If an inpatient classified as PCAP C is not responding to the current antibiotic within 72 hours, consider consultation with a specialist because of the following possibilities (Grade D)

a. penicillin resistant Streptococcus pneumoniae; or

b. Presence of complications (pulmonary or extrapulmonary ); or

c. Other diagnosis

3. If an inpatient classified as PCAP D is not responding to the current antibiotic within 72 hours, consider immediate re-consultation with a specialist (Grade D)

When can switch therapy in bacterial pneumonia be started?

Switch from intravenous antibiotic administration to oral form 2-3 days after initiation of antibiotic is recommended in a patient (Grade D) who

a. Is responding to the initial antibiotic therapy ,

b. Is able to feed with intact gastrointestinal absorption; and

c. Does not have any pulmonary or extrapulmonary complications

What ancillary treatment can be given?

1. Among inpatients, oxygen and hydration should be given if needed (Grade D)

2. Cough preparations, chest physiotherapy, bronchial hygiene, nebulization using normal saline solutions, steam inhalation, topical solution, bronchodilators and herbal medicines are not routinely given in community-acquired pneumonia (Grade D)

3. In the presence of wheezing, a bronchodilator may be administered (Grade D)

How can pneumonia be prevented?

1. Vaccines recommended by the Philippine pediatric Society should be routinely administered to prevent pneumonia (Grade B )

2. Zinc supplementation (10 mg for infants and 20 mg for children beyond two years of age given for a total of 4 to 6 months ) may be administered to prevent pneumonia(Grade A)

3. Vitamin A (Grade A) , immunomodulators (Grade D) and vitamin C (Grade D) should not be routinely administered as a preventive strategy

Special Considerations

1. Malnutrition • Malnourished children have a significantly

higher risk of developing pneumonia compared to well nourished children

• Strep pneumoniae and Hemophulus influenzae should be considered as the most probable cause of pneumonia.

• Infection with TB and gram negative enteric bacilli should be considered in non responsive patients

TUBERCULOSIS

• No available studies on CAP in children with TB

• A child with TB can be malnourished therefore presumed to be immunocompromised

• Usual community acquired pathogens are considered the most probable cause of pneumonia

• In patients with extensive pulmonary parenchymal damage secondary to PTB , there is predisposition to infection with anaerobic organisms and Staph aureus

• CHD with either large volume left to right shunt or chamber enlargement increases the risk of CAP

• Chest xray studies helpful • Viral infections are the most frequent

etiologies

Congenital Heart Disease

Principles of therapy

• Antiviral agent should be given if a viral pathogen is being considered

• Empiric antibiotic therapy should be given if a bacterial pathogen is considered

• Observe cautious hydration • Provide oxygenation • Inhaled B2 agonists if with good response

Chlamydia pneumoniae has been associated with persistent type of asthma but not with acute exacerbations. 55% of asthmatics are colonized with atypical organisms in their airways

• Use of antibiotic in early childhood is associated with an increased risk of developing asthma and allergic disorders among those predisposed to atopic immune response

ASTHMA

• Viral URTI with atelectasis secondary to mucus plug because of asthma is often misdiagnosed as pneumonia

• In children without an apparent pneumonia, asthma is the most common cause of recurrent or persistent infiltrate on chest xray

DISCLAIMER

The recommendations contained in the document of the PPS,Inc,Committee on CPGS are intended to GUIDE practitioners in the detection (and management) of pediatric patients with the disease of interest.In no way should the recommendations be regarded as absolute rules,since nuances and peculiarities in individual cases or particular communities may entail differences in the specific approach.In the end, the recommendations should supplement, and NOT replace, sound clinical judgment made on a case to case basis.

Hope you learned something today.