Canadian Paediatric Society (CPS) Guideline Summarized

The following was adapted from the Canadian Paediatric Societys statement on Pneumonia in healthy Canadian children and youth:
Practice points for management. Please see the full statement for the full recommendations from the Canadian Paediatric Society.

Pneumonia in healthy Canadian children and youth: Practice points for management
Saux, NL, and Robinson, JL. (2011). Pneumonia in health Canadian children and youth: Practice points
for management, 16(7), 417-420.

Background:
Pneumonia is an acute inflammation of the parenchyma of the lower respiratory tract
caused by a microbial pathogen. Despite advances with vaccinations, an estimated 1 in
20 children younger than five years of age will contract pneumonia each year. These
guidelines apply to uncomplicated, community-acquired pneumonia in healthy,
immunized childen. They should not be used for children with severe pulmonary
pathology, chronic or recurrent pneumonia, aspiration pneumonia or in
immunocompromised children as they may require more intensive management. For
management of complicated pneumonia or empyema, click here.
Etiology:
Uncomplicated pneumonia can be caused by three broad categories of pathogens. The
likelihood of different etiologies varies based on the child's age, the season and the
community.
Viral Pneumonia - May predispose to secondary bacterial pneumonias:

Respiratory syncytial virus (RSV), parainfluenza virus, and human

metapneumovirus.
Influenza.

Typical Bacterial Pneumonia:

Streptococcus pneumoniae - Most common bacteria.

Staphylococcus aureus (including MRSA) - Rare, but can be seen in communities
where MRSA is prevalent.
Haemophilus influenzae type b - Rare in vaccinated children.
Group A Strep - Rare.

Atypical Bacterial Pneumonia:

Mycoplasma pneumoniae.
Chlamydophila pneumoniae.

Summarized by Mara Tietzen for pedscases.com

February 9, 2015

In infants and preschool children, viruses are the most common cause, but some
infections may be caused by typical bacteria. In school-age children atypical bacteria
emerge that are rarely seen in younger chidlren, and viruses (with the exception of
influenza) become less common.
Diagnosis:
Pneumonia is diagnosed by the clinical presentation and may be supported or
confirmed by a chest X-ray (CXR).
Clinical Presentation
There are many possible signs and symptoms that may be nonspecific, especially in
infants and younger children:

Acute onset of fever and tachypnea.

Chest pain or abdominal pain.
Cough
Decreased oxygen saturation.
Lack of interest in normal activities
Poor feeding or vomiting.
Respiratory distress - Indrawing, retractions and/or a tracheal tug.
Rigors - Suggest a bacterial cause.
Signs of consolidation - Dullness to percussion, increased tactile fremitus, reduced
vesicular breath sounds and increased bronchial breath sounds.
Signs of dehydration or sepsis.
Signs of effusion - Dullness to percussion, decreased tactile fremitus, decreased or
absent breath sounds.
Note: Wheeze suggests that asthma or bronchiolitis is a more likely cause than
pneumonia.

Investigations:
1. CXR:

Viral Pneumonia - Poorly defined nodules, patchy opacity, variable hyperinflation,

and no effusions.
Typical Bacterial Pneumonia - Lobar/segmental consolidiation, with or without
pleural effusions.
Atypical Bacterial Pneumonia - Focal infiltrates that appear more extensive than
clinical presentation would suggest.

2. Other investigations, including CBC with differential, blood culture, sputum samples,
pleural fluid culture or nasopharyngeal swabs are generally not required, but may be
used for children who are worsening or hospitalized.

Summarized by Chris Novak and Mara Tietzen for pedscases.com

Update February 19, 2015

Management:
Viral pneumonia - If confirmed on nasopharyngeal swab or is the most probable cause
based on the season and CXR findings:
Supportive Care - Rehydration and oxygen if required.
No antibiotics.
Consider antivirals if influenza suspected, child has risk factors for severe disease,
or requires hospital admission.
Bacterial pneumonia - If clinical picture and CXR are compatible, use this algorithm:

Step 1:
o Nonsevere with typical features - High-dose amoxicillin PO or ampicillin IV.
o Nonsevere with atypical features - Clarithromycin PO or azithromycin PO.
o Severe - Ceftriaxone IM/IV or cefotaxime IV AND clarithromycin PO or
azithromycin PO/IV.
Step 2:
o If influenza with secondary bacterial infection - Consider adding antiviral.
Step 3:
o If small effusion present - Treat as above, but follow up carefully.
o If moderate to large effusion present - Treat with ceftriaxone or cefotaxime, and
consider adding clindamycin.
Step 4:
o If MRSA suspected - Add vancomycin or linezolid to antibiotics listed above.

For guidelines for hospital admission, management in children with penicillin allergy,
and suggested dosages of medications, please see the original statement.
Expected clinical course and follow-up:
Clinical improvement should be evident within 48 hours of treatment with bacterial
pneumonia, but may take longer for viral pneumonia. If clinical improvement occurs,
repeat CXR is not recommended as radiographic resolution can take four to six weeks.
If the child does not improve as suspected, repeat a CXR to look for complications or
other causes.
Key Take-Home Points
1. Recognize that the clinical presentation of pneumonia can be very nonspecific, especially in infants and younger children.
2. Chest radiographs should be used to diagnosis pneumonia whenever possible.
They should also be repeated to re-assess deterioration, or lack of improvement
following a diagnosis.
3. Chest radiographs are NOT indicated to track illness improvement.
4. Nasopharyngeal swabs for viral serology are not indicated for outpatients with
mild to moderate symptoms, but should be completed in any child admitted to
hospital.
5. Bacterial pneumonia should improve within 48 hours of initiation of appropriate
antibiotic therapy, (viral may take slightly longer). Be sure to re-evaluate diagnosis
if this improvement is not observed.
Summarized by Chris Novak and Mara Tietzen for pedscases.com
Update February 19, 2015