News Author: Emma Hitt, PhD
CME Author: Penny Murata, MD
CME/CE Released: 09/08/2011; Valid for credit through 09/08/2012
Clinical Context
The leading cause of death in children worldwide is pneumonia, as reported by Wardlaw and colleagues in the September 23, 2006, issue of The Lancet. Community-acquired pneumonia (CAP) in children is defined by signs and symptoms of pneumonia in previously healthy children from an infection that was acquired outside of the hospital, according to the British Thoracic Society in the May 2002 issue of Thorax.
The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) convened an expert panel to review the management of CAP. The PubMed database was reviewed through May 2010. The expert panel included clinicians and investigators who represented community pediatrics, public health, critical care, emergency medicine, hospitalist medicine, infectious diseases, pulmonology, and surgery. These clinical practice guidelines address the management, diagnosis, antimicrobial and adjunct surgical therapy, and prevention of CAP in otherwise healthy children older than 3 months in the outpatient and inpatient settings.
Study Synopsis and Perspective
The first-ever guidelines on the diagnosis and treatment of CAP in infants and children, from PIDS and IDSA, emphasize the importance of immunizations, including a yearly influenza vaccine, to protect children from life-threatening pneumonia.
A 13-member panel, led by John S. Bradley, MD, with the Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, in California, authored the new guidelines published online August 30 and to appear in the print October 1 issue of Clinical Infectious Diseases. The document presents 92 specific recommendations in all, each with varying levels of evidence.
Currently, guidelines exist for the diagnosis and treatment of pneumonia in adults, but in the pediatric setting, bacterial pneumonia often takes a different course, even when caused by the same pathogens. Consequently, there is widespread variability in the treatment of CAP among children.
The current document is "designed to provide guidance in the care of otherwise healthy infants and children and addresses practical questions of diagnosis and management of CAP evaluated in outpatient (offices, urgent care clinics, emergency departments) or inpatient settings in the United States," Dr. Bradley and colleagues write.
Recommendations for Diagnosis
"Diagnostic methods and treatments that work well in adults may be too risky and not have the desired result in children," noted Dr. Bradley in an accompanying written release from the PIDS and IDSA.
Regarding diagnosis, the guidelines state that blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP treated in the outpatient setting.
"In these cases, there is no need to perform unnecessary medical interventions such as using x-rays (which expose the child to radiation needlessly) or prescribing antibiotics (which kill bacteria, not viruses, and may foster drug-resistant bacteria)," the written release states.
However, blood cultures should be performed in children "who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy," the study authors write.
Hospitalization Based on Symptoms in Infants
The guidelines also recommend that infants 3 to 6 months old with suspected bacterial pneumonia be hospitalized, even if the pneumonia is not confirmed by blood tests. "Blood testing in children often isn't accurate, so physicians need to pay close attention to symptoms, and, if unsure, err on the side of treating," Dr. Bradley indicates.
Strong Recommendation for Immunizations
All children and adolescents at least 6 months old should be immunized annually with vaccines for influenza virus to prevent CAP, which the study authors state is a strong recommendation, based on high-quality evidence.
Parents of children younger than 6 months should be vaccinated against influenza because these children cannot receive the preventive vaccine.
Amoxicillin Sufficient for First-Line Therapy
In addition, amoxicillin should be used as first-line therapy for bacterial pneumonia, but more powerful antibiotics are not needed. Methicillin-resistant Staphylococcus aureus should be considered as a cause of pneumonia if first-line treatment is unsuccessful.
According to the guidelines, overtreatment is a critical concern. Most cases of pneumonia in preschool-aged children are of viral origin and will therefore not develop into life-threatening bacterial pneumonia.
Because of the difficulty in studying children, the guidelines all call for more research in several areas.
"With these guidelines, we are hopeful that the standard and quality of care children receive for community-acquired pneumonia will be consistent from doctor to doctor — providing much better treatment outcomes," Dr. Bradley indicates.
"We’re hopeful that in following these guidelines, physicians and hospitals will collect data and the results can be compared," he notes. "We envision this as the first of many revisions of guidelines to come."
Guidelines Meet an Important Unmet Need
Carrie Byington, MD, a pediatric infectious disease specialist with the Department of Pediatrics, at the University of Utah School of Medicine in Salt Lake City, notes that these guidelines address a very important unmet need for all practitioners who care for children.
"Pneumonia is one of the most common reasons for hospitalization for children in the United States, and there's a huge variation in the care that's delivered to children," she told Medscape Medical News. Dr. Byington is an author on the new guidelines and is vice chair of the American Academy of Pediatrics Committee on Infectious Diseases.
"Often the care of children is not evidence based and result in both over- and undertreatment of children and less than ideal outcomes," she said. "This is the first attempt to review all the evidence available in the scientific literature and to provide explicit guidelines for practitioners that could assist them in their decision making for children with pneumonia."
Areas of Interest
According to Dr. Byington, pediatricians in primary care will probably be most interested in the guidelines for diagnostic testing and the recommendation for antibiotic therapy. Pediatricians in the hospital setting will also be interested in the guidelines for hospitalized children, including diagnostic testing and treatment of complicated pneumonia.
"We also really want to stress the prevention of pneumonia through immunization, so there is a large section to the research that demonstrates the importance of this," she said.
This study was supported by the IDSA. Some of the study authors have disclosed various financial relationships with Wyeth/Pfizer, Sanofi Pasteur, Pfizer, GlaxoSmithKline, Novartis, Baxter Health Care, Halozyme Therapeutics, Pricara (Ortho-McNeil-Janssen), Rox-888, Venasite, the National Institutes of Health, and/or the Robert Wood Johnson Foundation.
Study Highlights
- Indications for hospitalization are moderate to severe CAP based on respiratory distress and hypoxemia (SpO2 < 90%), age younger than 3 to 6 months, suspected bacterial cause, virulent pathogen, and concern about home care or follow-up.
- Indications for admission to the intensive care unit are the need for ventilation, impending respiratory failure, sustained tachycardia, inadequate blood pressure or perfusion, pulse oximetry reading of less than 92% on 0.50 or more of inspired oxygen, and altered mental status.
- Blood culture indications are no improvement after initiation of antibiotic use, hospitalization for moderate to severe or complicated bacterial CAP, or follow-up of blood culture results positive for S aureus.
- If indicated, tests can be done for sputum Gram stain and culture, respiratory viruses, and Mycoplasma pneumoniae.
- Complete blood cell count should be obtained in cases of severe pneumonia.
- Acute-phase reactants (erythrocyte sedimentation rate, C-reactive protein, serum procalcitonin levels) should not be used to distinguish a viral vs bacterial cause, but they can be useful for serious disease.
- Pulse oximetry is indicated in all children with pneumonia and suspected hypoxemia.
- Chest radiographs should be done in the outpatient setting for cases of hypoxemia, significant respiratory distress, or failed antibiotic therapy and should also be performed in all hospitalized patients.
- Follow-up chest radiographs are recommended in children whose condition does not improve within 48 to 72 hours after starting antibiotic therapy and for cases of recurrent pneumonia involving the same lobe.
- Most preschool-aged children with CAP have a viral pathogen and do not require antimicrobial therapy in the outpatient setting.
- Anti-infective treatment in the outpatient setting includes the following:
- Amoxicillin to treat Streptococcus pneumoniae in previously healthy, appropriately immunized infants, preschool-aged children, and school-aged children with mild to moderate bacterial CAP
- Macrolide antibiotic for primarily school-aged children with CAP from a suspected atypical pathogen
- Influenza antiviral treatment of moderate to severe CAP from suspected influenza, despite pending or negative influenza test results
- Anti-infective treatment in the inpatient setting includes the following:
- Ampicillin or penicillin G for fully immunized infants or school-aged children
- Third-generation parenteral cephalosporin (ceftriaxone or cefotaxime) for cases of incomplete immunization, in locations of invasive pneumococcal strains with high-level penicillin resistance, and life-threatening infection
- Empiric addition of an oral or parenteral macrolide to a beta-lactam antibiotic for suspectedMycoplasma pneumoniae and Chlamydophila pneumoniae
- Vancomycin or clindamycin plus a beta-lactam antibiotic for suspected S aureus
- The appropriate antimicrobial treatment duration is 10 days, but shorter courses might be effective or longer courses might be needed.
- Parapneumonic effusion identified by chest radiograph, ultrasonography, or computed tomography might need drainage, depending on its size and degree of respiratory compromise.
- Options for parapneumonic effusion drainage are chest thoracostomy tube drainage plus fibrinolytic agents or video-assisted thoracoscopic surgery.
- Criteria for hospital discharge include overall clinical improvement for at least 12 to 24 hours, pulse oximetry of more than 90% in room air for at least 12 to 24 hours, baseline mental status, ability to tolerate home anti-infective and oxygen regimens, no deterioration 12 to 24 hours after removal of the chest tube, and attention to barriers to home care.
- Appropriate immunization for children and caregivers can prevent CAP.
Clinical Implications
- The recommended anti-infective treatment of previously healthy, appropriately immunized children in the outpatient setting includes amoxicillin for preschool and school-aged children with mild to moderate bacterial CAP, macrolide antibiotics for school-aged children with suspected atypical bacterial pathogens, and influenza antiviral treatment in children with moderate to severe CAP from a suspected influenza virus.
- The recommended anti-infective treatment of children hospitalized with CAP includes ampicillin or penicillin G for appropriately immunized children; a third-generation parenteral cephalosporin for children who are not fully immunized, those in locations with high-level penicillin resistance, or in cases of life-threatening infection; macrolide treatment plus a beta-lactam antibiotic for suspected M pneumoniae and C pneumoniae; and vancomycin or clindamycin plus beta-lactam treatment of suspected S aureus.