PCAP Guidelines

PCAP GUIDELINESPCAP GUIDELINES

Etiology

• Outpatient and in-patients: bacterial > viral

• For bacterial: Streptoccocus pneumoniae> H.

influenzae> Mycoplasma sp.> Chlamydia sp.

VariablesPCAP A

Minimal

PCAP B

Low

PCAP C

Moderate

PCAP D

High

Co-morbids None + + +

Compliant

Caregiver

+ + None None

Ability to + + None None

Risk Classification

Ability to

Follow up

+ + None None

Dehydration None Mild Moderate Severe

Feeding Yes Yes No No

Age > 11 months > 11 months < 11 months < 11 months

RR 2-12 mos > Or = 50 > 50 > 60 > 70

1-5 yrs > Or = 40 > 40 > 50 > 50

> 5 yrs > Or = 30 > 30 > 35 > 35

VariablesPCAP A

Minimal

PCAP B

Low

PCAP C

Moderate

PCAP D

High

Retractions Intercostal/

subcostal

Supra-

clavicular

Head bobbing + +

Cyanosis + +

Grunting +

Apnea +

Sensorium Awake Awake Irritable Lethargic/ Sensorium Awake Awake Irritable Lethargic/

stuporous/

comatose

Complications + +

Action OPD OPD Admit to

wards

Admit to ICU

Follow up at

end of

treatment

Follow up

after 3 days

Refer to

specialist

Diagnostics

• No diagnostic aids initially requested for PCAP

A or B managed on an outpatient basis

• Routine exams for PCAP C or D:

– CXR PAL– CXR PAL

– WBC count

– CS: blood (for PCAP D), pleural fluid, ETA upon

intubation

– Blood gas/O2 sat

Diagnostics

• Sputum CS for older children

• ESR and CRP are not routinely requested

Predictors of bacterial pathogen

• Clinical prediction using a bacterial

pneumonia score

– BPS ≥ 4 ~ (+) bacterial pathogen in hospitalized

patients 1 month – 5 yearspatients 1 month – 5 years

• Probable organisms acc. to age

– Increase age, higher chance of bacterial pathogen,

increasing frequency of atypical organism

• Decreased breath sounds

Treatment

• Antibiotics are recommended in:

1. Patients classified as either PCAP A or B and is:

(a) beyond 2 years of age; or (b) having high

grade fever without wheezegrade fever without wheeze

2. Patients classified as PCAP C and is: (a) beyond 2

years of age; (b)having high grade fever without

wheeze; (c) having alveolar consolidation in chest

x-ray; (d) or having WBC count > 15,000

3. Patients classified as PCAP D

Treatment

• Empiric treatment (bacterial etiology):

– PCAP A or B w/o previous antibiotic: Amoxicillin

45 mg/kg/day in 3 divided doses x 3 days (min)

• Macrolide if w/ hypersensitivity of amoxicillin• Macrolide if w/ hypersensitivity of amoxicillin

• Other regimens: Co-trimoxazole, azithromycin,

erythromycin, co-amoxiclav, clarithromycin

– PCAP C w/o previous antibiotic and has complete

immunization against Hib: Penicillin G 100,000

‘u’/kg/day

• Oral amoxicillin in patients who can tolerate feeding

(comparable to parenteral penicillin)

Treatment

• Empiric treatment (bacterial etiology):

– PCAP C w/o Hib immunization: IV ampicillin 100

mg/kg/day in 4 divided doses

• Monotherapy (parenteral ampicillin) or combination • Monotherapy (parenteral ampicillin) or combination

therapy (IV penicillin + chloramphenicol) in patients

who cannot tolerate feeding

• Other regimens: Amoxicillin/sulbactam, cefuroxime,

chloramphenicol

– PCAP D: consult a specialist

Treatment

• If CA-MRSA suspected, refer immediately to

the appropriate specalist.

• Strategies in clinical management of MRSA:

– Follow antibiotic susceptibility based on culture – Follow antibiotic susceptibility based on culture

studies

– Vancomycin remains to be the 1st line therapy for

severe infections possibly caused by MRSA

– CA-MRSA were more likely to be synergistically

inhibited by vancomycin + gentamicin vs.

vancomycin alone

Treatment

• Initial treatment (viral etiology):

– Ancillary treatment

– Oseltamivir 2 mg/kg/dose BID x 5 days may be

given for laboratory confirmed influenzagiven for laboratory confirmed influenza

Response to antibiotics

• Decrease in respiratory signs (i.e. tachypnea)

and defervescense within 72 hours after

initiation of antibiotic – FAVORABLE

– Nonsevere: RR>5 bpm slower than baseline– Nonsevere: RR>5 bpm slower than baseline

– Severe: defervescense, decrease in tacypnea &

chest indrawing, increase in O2 sat & ability to

feed within 48 hours

• Persistence of symptoms beyond 72 hours

after initiation of antibiotics – RE-EVALUATE


• Improved: RR < age-specific range without

chest indrawing or any danger signs (central

cyanosis, inability to drink, abnormally sleepy

or convulsions)or convulsions)

• Treatment failure

– Same: RR > age-specific range WITHOUT chest

indrawing or any danger signs

– Worse: Developed chest indrawing or any of the

danger signs


• If a patient w/ PCAP A or B is not responding

to antibiotics w/in 72 hours, consider:

– Change the initial antibiotic; or

– Start an oral macrolide; or– Start an oral macrolide; or

– Re-evaluate diagnosis

• Causes of treatment failure: co-infection w/

RSV, non-adherence to treatment


• If a patient w/ PCAP C is not responding to

antibiotics w/in 72 hours, consider:

– Penicillin resistant Strep pneumoniae; or

– Presence of pulmonary or extrapulmonary– Presence of pulmonary or extrapulmonary

complications; or

– Other diagnosis

• Causes of treatment failure: antibiotic

resistance, clinical sepsis, progressive

pneumonia, mixed infection


• If a patient w/ PCAP D is not responding to

antibiotics w/in 72 hours, consider:

– Immediate re-consultation w/ a specialist


• Switch from IV to oral 2-3 days after initiation

of antibiotics recommended if:

– Responding to the initial antibiotic therapy

– Able to feed w/ intact GI absorption– Able to feed w/ intact GI absorption

– Without pulmonary or extrapulmonary

complications

• Switch from 3 days of IV ampicillin to 4 days of

amoxicillin (preferred) or cotrimoxazole

Ancillary treatment

• Oxygen and hydration if needed among

inpatients

• Cough preparations, chest physiotherapy,

pNSS nebulization, steam inhalation, topical pNSS nebulization, steam inhalation, topical

solution, bronchodilators are not routinely

used

• A bronchodilator may be used if with

wheezing

Prevention

• Pneumococcal and Hib vaccination

• Zinc supplementation may be administered to

prevent pneumonia

• Handwashing using antibacterial soaps• Handwashing using antibacterial soaps

• Breastfeeding

PCAP Guidelines

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