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,2006 PhP 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 communitycommunity-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)

fever, tachypnea and tachycardia and; b. At least one abnormal chest finding of diminished breath sounds, rhonchi, crackles or wheezes
a.

WHO age specific criteria for tachypnea

AGE 2-12 mos 1-5 years >5 years RR >50 >40 >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 PneumoniaPneumoniaRelated Mortality

Variables PCAP A Minimal Risk None Yes Possible None Able >11 mo PCAP B Low Risk Present Yes Possible Mild Able >11 mo PCAP C Moderate Risk Present No Not possible Moderate Unable < 11 mo PCAP D High Risk Present No Not possible Severe Unable < 11 mo 1. Co-morbid illness 2. Compliant caregiver 3. Ability to follow-up 4. Presence of Dehydration 5. Ability to feed 6. Age 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

None

None

Intercostal/ Subcostal Present Present None None Irritable

a. b. c. d. e.

Head Bobbing Cyanosis Grunting Apnea Sensorium

None None None None Awake

None None None None Awake

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

9. Complications (effusion , pneumothorax)

None

None

Present

ACTION PLAN

OPD follow-up at the end of treatment

OPD followup 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 recommended 1. 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 xray (Grade B) or d. Having white blood cell count > 15, 000 (grade C)
3. For a patient classified as PCAP D (Grade D)

FEATURES Fever Wheeze

BACTERIAL T> 38.5o C Absent

VIRAL T< 38.5o C 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 reconsultation 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

Congenital Heart Disease

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

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

ASTHMA
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

 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.