Children Pneumonia

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Guidelines for the Management of Community-

Acquired Pneumonia in Children

PING-INGLEE 1, CHENG-HSUNCHIU2, PO-YENCHEN3, CHIN-YUNLEE 1, TZOU-YIENLIN2AND

Taiwan Pediatric Working Group for Guideline on the management of CAP in children 4

I. ETIOLOGY

A. The prevalent pathogen is different in different age

groups.

B. Atypical pneumonia

1. Viral infections prevail in children younger than

5 years of age, especially respiratory syncytial

virus. Other viral etiologies include influenzavirus, parainfluenza virus, adenovirus, human

metapneumovirus, rhinovirus, and cytomegalovirus.

2.Mycoplasma pneumoniae infections prevail in

children older than 2-5 years of age. M. pneumoniae

and Chlamydophila pneumoniaeare responsible

for 40-50% of atypical pneumonia in children of this

age in Taiwan. Legionella pneumophilainfection

is relatively uncommon in children. Chlamydia

trachomatisinfection may occur in children younger

than 6 months of age.

C. Pyogenic bacterial pneumonia

1. Streptococcus pneumoniae is the single most

common cause of pyogenic bacterial pneumoniain children beyond the first few weeks of life.

Haemophilus influenzae type b, Staphylococcus

aureus are also possible offending bacteria

pathogens in children younger than 5 years.

2. S. aureusis one common pathogen in pneumonia

associated with chest trauma or influenza virus

infection.

D.Mycobacterium tuberculosisinfection is still prevalent

in Taiwan and should be put into the list of differential

diagnoses for community-acquired pneumonia (CAP)

in children.

E. Mixed infection is not uncommon in children with

CAP.

Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine1,

Taipei, Taiwan; Division of Infectious Diseases, Department of Pediatrics, Chang Gung Childrens Hospital, Chang

Gung Memorial Hospital, Chang Gung University, College of Medicine2, Taiwan; Section of Pediatric Infectious Diseases,

Department of Pediatrics, Taichung Veterans General Hospital3, Taichung; Taiwan Pediatric Working Group for Guideline

on the management of CAP in children 4 : Chin-Yun Lee, Ping-Ing Lee, Frank Leigh Lu, Li-Min Huang, Wu-Shi-

un Hsieh, Ren-Bin Tang, Wen-Jue Soong, Chih-Chien Wang, Fu-Yuan Huang, Rey-In Lien, Cheng-Hsun Chiu, Yhu-

Chering Huang, Kin-Sun Wong, Po-yen Chen, Ching-Chuan Liu, Kao-Pin Hwang, Yung-Zen Lin.

Received: June 7, 2007. Revised: July 7, 2007. Accepted: August 7, 2007.

Address reprint requests to: Dr. Tzou-Yien LIN, 5-7 Fu-Hsin Street, Kweishan333, Taoyuan, Taiwan.

E-mail: [email protected]

167

The causes of community-acquired pneumonia (CAP)

in children as reported in the medical literature must be

interpreted with caution, largely because many methods

for assignment of etiology are inadequate. Pyogenic

bacteria present the most difficult challenge, because

the normal upper respiratory tract flora frequently contains

potential pathogens and sputum collection may be difficult

in young children. The presence of bacteremia confirmsthe cause, but blood culture is positive in less than one

tenth of children with bacterial pneumonia.1

Epidemiologic information frequently is useful in

guiding the search for the cause of pneumonia. Certain

viruses, particularly respiratory syncytial virus (RSV),

rhinoviruses, and influenza virus, as well asMycoplasma

pneumoniae, are strongly seasonal in temperate areas.

However, as being located in subtropical region, the

seasonal tendency of these pathogens in Taiwan is not

as obvious as that in temperate areas.2,3In other instances,

the pattern of family illness can hint at the cause,

especially the highly contagious influenza virus. Table

1 lists the etiological agents for pneumonia in children,and Table 2 shows the distribution of these agents in

children by age.

Respiratory viruses are the most common cause of

CAP in children younger than 5 years old. RSV is most

prevalent in children younger than 1-2 years of age.4

Adenovirus has been reported to be associated with severe

diseases in Taiwan.5 In temperate areas, RSV and

influenza virus infections occur in winter epidemics, and

parainfluenza viruses and rhinoviruses are more common

in autumn and spring. Infections due to adenoviruses

occur throughout the year. However, a recent study in

Taiwan showed that monthly distribution of RSV

infections in Northern Taiwan showed a bimodal pattern

Review Article


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P.I. LEE, C.H. CHIU, P.Y. CHEN, et al. 169Acta Paediatr Tw

streptococcal pneumonia are rapidly progressive and

severe, frequently leading to hypoxemia and effusion

within hours. Mycobacterium tuberculosisthat is still

prevalent in Taiwan should be put into the lis t of

differential diagnoses for CAP in children.15

II. CLINICAL MANIFESTATIONS

A. Features of pyogenic bacteria pneumonia

1. Sudden deteriorated respiratory condition after an

apparently mild respiratory infection.

2. Severely debilitated with poor activity when the

body temperature is normal.

3. Tachypnea (respiratory rate > 60/min for infants

< 11 months, > 40/min for children between 1 year

and 4 years, and > 30/min for children older than

5 years).4. Oxygen saturation 92%, cyanosis.

5. Septic signs, such as consciousness disturbance,

bleeding tendency, and hypotension.

6. Signs of respiratory distress, including nasal flaring,

grunting, and chest wall retraction.

7. Lung consolidation, cavity formation.

B. Features of atypical pneumonia:

1. Children retain normal activity without features of

pyogenic bacteria pneumonia.

2. Conjunctivitis, otitis media, skin rash, and

wheezing may be more common.

There have been many studies conducted in an effortto differentiate bacterial etiologies of pneumonia from

viral infections based on clinical manifestations. In

general, none of the symptoms or signs can be considered

specific. The onset of pyogenic bacterial pneumonia may

be abrupt and may follow days of mild viral respiratory

illness. The patient is ill, sometimes toxic appearing.

Tachypnea, respiratory distress, hypoxemia, and lung

consolidation or cavity formation are predictive of severe

or pyogenic bacteria pneumonia16-18 A study from

developing world showed that oxygen desaturation was

associated with a greater risk of death, and tachypnea

is closely related to hypoxemia.19Several scoring systems

have been proposed to predict the severity and mortalityof CAP However, none of them has been modified

for children, and none has been examined in pediatric

patients.19,20

In contrast to pyogenic bacterial pneumonia, children

with atypical pneumonia, including those caused by

M. pneumoniae, C. pneumoniae, L. pneumophila

and viruses, usually appear healthy without apparent

respiratory distress. Presence of arthralgia and erythema

multiforme may suggestM. pneumoniaeinfection. As

compared with pyogenic bacterial pneumonia, some

studies suggest that children with atypical pneumonia

may have a higher incidence of conjunctivitis,21otitis

media,21and wheezing.22,23However, some features

thought to be specific for viral illness were not observed

more frequently in children with atypical pneumonia,

including rhinorrhea, illness in family members, and

myalgia.22,23

III. DIAGNOSIS

A. Acute phase reactants cannot reliably differentiate

between pyogenic bacterial pneumonia and atypical

pneumonia in children.

B. Image studies:

1. Chest radiography

a. Chest radiography should be considered in

children with an unexplained fever after excludingthe possibility of common infectious diseases,

and in those with a prolonged fever.

b. Chest X-ray findings can hardly differentiate

among different etiologies. Bulging interlobar

fissures and cavitations are suggestive of pyogenic

bacteria infection.

2. Chest ultrasonography is useful to evaluate the

presence of consolidation and pleural effusion, and

is helpful to guide thoracocentesis or chest tubing.

3. Computerized tomography of the chest may provide

details of pneumonia, and is indicated before

surgical interventions.

C. Microbiological investigations:1. Sputum:

a. Gram stain, and acid-fast stain if necessary,

should be done before the initiation of antibiotics.

b. The result of sputum culture may not represent

the true etiology of pneumonia. However,

with a qualitative count of gram stain

(polymorphonuclear cells > 25/high-power field

and epithelium < 10/ high-power field, with or

without phagocytosis of polymorphonuclear cells),

it does provide some help to adjust the

antimicrobial agent during the disease course.

c. For patients with suspectedM. tuberculosis

infection, acid-fast stain and mycobacteria cultureof the sputum should be done for at least 3 times.

For children whose sputum is not available,

gastric lavage for mycobacterial examination

should be done in the early morning before meals

for 3 consecutive days.

d. Direct fluorescent antigen test is available for

L. pneumophila.

2. Nasopharyngeal or oropharyngeal swab: The

specimens may be sent for virus culture and viral

antigen detection that are more useful for young


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Community-acquired pneumonia Vol. 48, No. 4, 2007170

children.

3. Blood culture should be performed in all children

with suspected pyogenic bacterial pneumonia.

4. A high titer of cold agglutinin may suggest

mycoplasma pneumonia. However, its specificity

is low.

5. A 4-fold rise of specific serum IgG titer or a single

positive IgM response indicates acute infection.

6.Urinary antigen tests are available for L.

pneumophila serogroup I and S. pneumoniae.

Although the pneumococcal antigen test is less

specific in children, it has a good negative

predictive value for the diagnosis of S. pneumoniae

pneumonia.

7. Tuberculin skin test should be performed whenM.

tuberculosis infection is suspected.

C. Invasive procedures:

1. The pleural fluid from thoracocentesis should betested for:

a. White count and differentials, protein, sugar,

lactate dehydrogenase and pH value.

b. Gram stain and acid-fast stain.

c. Antigen test for S. pneumoniae and H.

influenzaetype b may be helpful.

d. Culture for bacteria and, if suspected, virus and

M. tuberculosis .

2. Bronchoalveolar lavage and lung biopsy may be

considered in some difficult cases.

White cell count, neutrophil count, percentage of

immature neutrophil, erythrocyte sedimentation rate, andC-reactive protein (CPR) may reflect the severity of

infections, and are therefore believed to be able to

differentiate between pyogenic and nonpyogenic infections.

However, serum CRP was not useful to distinguish

between pneumococcal, chlamydial, or viral etiology

in children with pneumonia in a prospective study.24

Following an acute-phase stimulus, CRP values peak

at approximately 48 hours.25Timing of CRP test should

be considered in interpretation. Acute phase reactants

may only be useful to monitor the treatment response,

and to distinguish between fever and hyperthermia that

is not caused by an inflammatory response.

There has been some debates about the optimal timingfor chest X-ray examination in children with respiratory

symptoms. One study of 522 children aged 2 to 59 months

that were randomly allocated to have a chest radiograph

or not showed that there was a marginal improvement

in time to recovery which was not clinically significant.

It was concluded that routine use of chest radiography

is not beneficial in ambulatory children aged over 2 months

with acute lower respiratory-tract infection.26Another

study of 278 children aged 5 years or less suggested that

chest radiography should be considered a routine

diagnostic test in children with a temperature of 39

or greater and white count of 20,000/mm3or greater

without an alternative major source of infection. In that

study, pneumonia was found in 32 of 79 (40%) of those

with findings suggestive of pneumonia and in 38 of 146

(26%) of those without clinical evidence of pneumonia.27 Although chest radiography should not be performed

routinely in children with mild uncomplicated acute lower

respiratory tract infection,18it may be indicated in selective

patients, including an unexplained fever after excluding

the possibility of common infectious diseases, and a

prolonged fever with or without respiratory manifestations.

Chest X-ray findings can hardly differentiate among

different etiologies, especially for interstitial infiltrations

and pneumonic patches. Lung consolidation and pleural

effusion may be observed in pyogenic bacterial pneumonia

and pneumonia caused by M. pneumoniae , C.

pneumoniae, andL. pneumophila.

6

Bulging interlobarfissures and cavitations are suggestive of pyogenic bacteria

infection.28,29

Chest ultrasonography is simple, ready to use, and

not associated with radiation. It is useful to evaluate

the presence of consolidation and pleural effusion, and

is helpful to guide thoracocentesis or chest tubing, and

for follow-up. Therefore, it may be considered when

chest X-ray shows the presence of consolidation or pleural

effusion.

Computerized tomography (CT) of the chest may

provide details of pneumonia, including the extent of

consolidation, cavitation, lung abscess, and empyema.

It is indicated before surgical interventions, such as video-assisted thoracoscopic surgery (VATS), and decortication

of empyema. It may also be useful to evaluate complicated

pneumonia with poor clinical response. High-resolution

CT has been suggested to be more sensitive than chest

radiograph to detect pulmonary infiltrates.30However,

it should not be used routinely.

For the majority of patients treated as outpatients,

a specific microbiological diagnosis may not be necessary.

The investigations are important for patients admitted

to hospital with pneumonia. Sputum gram staining,

and acid-fast staining if necessary, should be performed

before the initiation of antibiotics. The sputum may be

hard to be obtained in children and the result of sputumculture may not represent the true etiology of pneumonia.

However, with a quantitative count of gram stain, it

does provide some help to adjust the antimicrobial agent

later on.

In Taiwan, it is recommended that at least 3 sputum

specimens should be sent for acid-fast stain and

mycobacterial culture in patients with suspected M.

tuberculosisinfection. Because the sputum cannot be

obtained in many children, gastric lavage in the early

morning before meals for 3 consecutive days is also


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a proper specimen for mycobacteria study.31

Direct fluorescent antigen test is a reliable test for

L. pneumophila. It may be performed in selected

patients. Sputum obtained from bronchoscope has better

sensitivity.

Because viral etiologies are more prevalent in younger

children with CAP, nasopharyngeal or oropharyngeal

swab may be sent for virus culture and viral antigen

detection, including RSV, influenza virus A and B,

parainfluenza virus, and adenovirus. However, laboratory

quality should be certificated for these tests.

Blood culture should be performed in all children

with suspected bacterial pneumonia before receiving

antibiotics. However, the isolation rate is no more than

10-20%.32In older children, 2 blood cultures may be

attempted to increase the diagnostic sensitivity.32

Cold agglutinin is a nonspecific antibody response

inM. pneumoniaeinfection. It is a sensitive test, butits specificity is low and an elevated titer may also be

seen in other causes of CAP. Several serological tests

are available for the diagnosis of M. pneumoniae,

Chlamydophila pneumoniae, Chlamydia trachomatis,

L. pneumophila, and common respiratory viruses. A

4-fold rise of IgG titer or a single positive IgM response

indicates acute infection. A single high titer of IgG is

not diagnostic.

Legionella uninary antigen test identifies only L.

pneumophilaserogroup I, which is claimed to be the

most common type causing clinical illness. A study in

Taiwan showed that urine antigen test can detect only

17.3% of 237 patients with L. pneumophila infection.33A negative test does no exclude the diagnosis.

Pneumococcal urinary antigen test is an acceptable

test to augment diagnostic methods for S. pneumoniae

infection. The sensitivity ranged between 50% and 80%,

and the specificity is about 90% in adults.34,35Studies

involving children have documented the lack of specificity.36,37Although many authors suggest that a low specificity

of the test may be attributed to that the test may give

a false-positive result in children with colonization, it

is more appropriate to say that the test may also be positive

in S. pneumoniaeinfections other than pneumonia,

such as otitis media.38The test has a high sensitivity

and a good negative predictive value for the diagnosisof S. pneumoniaepneumonia in children.

Bacille Calmette-Gurin (BCG) is routinely given

to children in Taiwan. Although the vaccination may

interfere with the interpretation of tuberculin reaction,

studies in Taiwan showed than BCG vaccination did not

appear to limit the usefulness of tuberculin skin test as

a tool for diagnosing tuberculosis.39 The tuberculin

reactivity toward BCG is usually lost 5-10 yr after

vaccination.40

Significant pleural effusion should be aspirated for

etiological diagnosis, especially when the effusion is

> 10 mm in thickness on the lateral decubitus view or

chest ultrasonography.32,41Gram stain and acid-fast stain

should be routinely done. White count and differentials,

protein, sugar, lactate dehydrogenase and pH value are

helpful to differentiate among transudate, and

uncomplicated or complicated parapneumonic pleural

effusions.41 The sensitivity of culture to define the

offending bacteria is usually limited but can be improved

by antigen detection.42,43Culture for M. tuberculosis

and viruses, though being less frequently seen, should

be done in suspected cases.

Invasive procedures, including bronchoalveolar lavage

and lung biopsy, should not be routinely done. Analysis

of sputum from bronchoalveolar lavage may have a better

correlation with pneumonia. However, it is technically

difficult in young children and can only be considered

in some difficult cases.

IV. GENERAL MANAGEMENT

A. Decision for hospitalization

1. Children with the following conditions that may

be suggestive of a grave illness are not recommended

to be cared at home:

a. Features of severe bacterial pneumonia (see II-

A).

b. Signs of dehydration.

c. Neonates and children with immunodeficiency.

d. Caretakers not able to provide appropriateobservation or supervision.

2. If the clinical condition is aggravated, or is not

improving after 48 hours on treatment at home, the

child should be reviewed by a pediatric specialist.

B. Children who have hypoxemia or respiratory distress

should receive oxygen therapy.

C. Intravenous fluids, if necessary, may be given at

80% maintenance level with monitoring of serum

electrolytes.

Children with CAP may be cared at home, especially

for those caused by atypical pathogens. As listed in II-

A, several clinical manifestations are predictive for asevere bacteria pneumonia that should be cared in

hospitals. Oral intake usually decreases in children

with pneumonia. If there are obvious signs of dehydration,

the child should also be hospitalized. CAP in neonates

and children with immunodeficiency are prone to being

more severe. Therefore, they should be treated more

aggressively in the hospital.

Hypoxemia and respiratory distress are important risk

factors of a severe disease.44 Oxygen therapy given by

nasal cannula, head box, face mask, or oxygen tent


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should be given to children with hypoxemia, especially

for those with oxygen saturation 92%.18 If blood

oxygenation is not improved after oxygen therapy, patient

should be cared for at an intensive care unit with positive-

pressure respiratory support, such as intubation and use

of ventilator.

V. ANTIBIOTIC THERAPY

A. Principle

1.Empiric use of antibiotics should take into

consideration the age and the disease severity of

the patients. Appropriate antibiotics should be given

as soon as possible after registration for hospitalized

patients.

2. Parenteral antibiotics should be given to children

with severe pneumonia.3. If fever or some grave clinical manifestations persist

beyond 48 hours after treatment, the treatment plan

should be re-evaluated and a follow-up chest image

study should be considered.

4. Oral switch of antibiotics: If the clinical condition

improves rapidly with all of the following

characteristics suggestive of a stabilized illness,

intravenous antibiotics may be considered to be

switched to oral ones.

a. Absence of septic signs, empyema, necrotizing

pneumonia and lung abscess.

b. Stabil ized vital signs for at least 48 hours,

including body temperature, heart rate,

respiratory rate, and blood pressure.

c. No growth on blood culture.

d. May be fed orally.

5. Duration of antibiotic treatment

a. Mycoplasma pneumonia and chlamydia

pneumonia may be treated by appropriate oral

antibiotics for 10 days. If azithromycin is used,

the treatment should be continued for only 3-

5 days.

b. Legionnaires' disease: For immunocompetent

children, azithromycin may be used for 5-10 days,

and other macrolides and fluoroquinolones may

be used for 10-14 days. For immunocompromised

children, macrolides plus fluoroquinolones or

rifampin may be used for 14-21 days.

c. Antibiotics should be given according to the

treatment response, and are usually used for at

least 7-10 days.d. Duration of antibiotic therapy may need to be

prolonged in complicated infections, such as

those complicated by bacteremia or meningitis,

Pseudomonas aeruginosainfection, empyema,

necrotizing pneumonia, and lung abscess.

B. Choice of antibiotics when the pathogen is known:

Current antibiotic-resistance rate of some important

respiratory pathogens in Taiwan include 70% of

penicillin-nonsusceptible S. pneumoniae(minimum

inhibitory concentration 0.12 g/mL), about 60%

of -lactamase-producingH. influenzae, and 50-

70% of community-acquired methicillin-resistantS.

aureus.


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D. Choice of antibiotics under special circumstances:

1. Broad-spectrum and potent antibiotics should be

used in children with sepsis, meningitis, or

complications that may endanger the life.

2. For children with disorders such as bronchiectasis,

chronic lung disease, and severe neuromuscular

disorders and have a history of recurrent pneumonia,

repetitive use of antibiotics, or prolonged use of

steroids, enteric gram-negative bacteria, including

P. aeruginosa, are more likely to be the offending

path oge n. Em pi ri c th era py ma y inc lu de

antipseudomonal -lactams with or without

aminoglycosides.

3. When S. aureus infection is a concern, such as

chest trauma or influenza-associated pneumonia,

antibiotics effective against methicillin-resistant S.

aureusmay be added to the empiric therapy.

E. Recommended dosage of empirical antibiotics (for

children older than 1 month of age):

1. Penicillin: 300,000-400,000 units/kg/day, q4-6h.

2. Ampicillin: 150-200 mg/kg/day, q6h.

3. Amoxicillin: 80-90 mg/kg/day, po tid.

4. Oxacillin: 100-300 mg/kg/day, q4-6h.

5. Ampicillin/sulbactam: 150-200 ampicillin mg/kg/

day, q6-8h.

6. Amoxicillin/clavulanate: 150-200 amoxicillin mg/

kg/day, iv q6-8h; 80-90 amoxicillin mg/kg/day,

po bid-tid.

7. Cefazolin: 50-100 mg/kg/daym, iv q8-6hv.

8. Cefuroxime: 100-200 mg/kg/day, iv q6-8h; 20-

30 mg/kg/day, po bid, may double the dose for

severe infection.

9. Ticarcillin/clavulanate: 200-300 ticarcillin mg/kg/

day, q6-8h.

10. Piperacillin/tazobactam: 200-300 piperacillin mg/

kg/day, q6-8h.

11. Cefotaxime: 150-200 mg/kg/day, q6h.

12. Ceftriaxone: 100 mg/kg/day, q12h - qd.

13. Ceftazidime: 100-150 mg/kg/day, q6-8h.

14. Cefepime: 100-150 mg/kg/day, q8-12h.

15. Imipenem: 60-100 mg/kg/day, q6h.

16. Meropenem: 60-100 mg/kg/day, q6-8h.

17. Erytrhomycin: 40 mg/kg/day, q6h.

18. Clarithromycin: 15 mg/kg/day, q12h.

19. Azithromycin: 10-12 mg/kg/day, qd.

20. Tetracycline: 25-50 mg/kg/day, po bid-qid.


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21. Minocycline: 4 mg/kg loading, then 2 mg/kg po

q12h.

22. Doxycycline: 4.4 mg/kg/day loading, then 2.2-

4.4 mg/kg po qd.

23. Vancomycin: 20-60 mg/kg/day, q6-8h.

24. Teicoplanin: 10 mg/kg q12h loading doses for 3

doses, then 10-20 mg/kg, qd.

25. Linezolid: 20-30 mg/kg/day, q8-12h.

26. Rifampin: 10-15 mg/kg/day, qd.

27. Gentamicin: 6-7.5 mg/kg/day, bid-qd.

28. Tobramycin: 6-7.5 mg/kg/day, bid-qd.

29. Netilmicin: 5.5-8.0 mg/kg/day, bid-qd.

30. Amikacin: 15-25 mg/kg/day, bid-qd.

31. Ciprofloxacin: 20-40 mg/kg/day, q12h.

Age and disease severity are the two most important

factors in deciding whether antibiotics should be used

or which antibiotics should be chosen. For example,viral infections are more prevalent in young children,4and it is recommended that young children presenting

with mild symptoms of lower respiratory tract infection

need not be treated with antibiotics.18Studies showed

that initiation of antibiotics within 4 to 8 hours after arrival

at hospital correlated strongly with the outcome.45,46

Appropriate antibiotics should be given as soon as possible

after registration for hospitalized patients.

Orally administered antibiotics are safe and effective

for children with community-acquired pneumonia that

is not associated with clinical manifestations suggestive

of a grave illness. Parenteral antibiotics can ensure a

rapidly rising high serum concentration and should begiven to children with clinical manifestations suggestive

of a severe pneumonia and to those who cannot be fed

orally.

Some viral pneumonia may have a prolonged fever,

and some bacterial pneumonia may have a persistent fever

after using appropriate antibiotics, especially for those

with consolidation and pleural effusion.6 However,

clinical conditions of bacteria pneumonia that are

responsive to antibiotics usually improved within 48 hours

after treatment with defervescence.6If fever or some

grave clinical manifestations persist beyond 48 hours

after treatment, the treatment plan should be re-evaluated

and a follow-up chest image study should be considered.There have been limited data published regarding

intravenous-to-oral sequential antibiotic therapy in Taiwan.47Some randomized studies suggested that intravenous-

to-oral switch of antibiotics may be feasible for some

clinically stable and antibiotic-responsive CAP.32Such

a practice may be able to reduce the cost of treatment

and the length of stay in the hospital. We recommend

that oral switch of antibiotics may be applied to CAP

in children without evidence of sepsis, empyema,

necrotizing pneumonia, and lung abscess when the

vital signs have been stabilized for at least 48 hours

and when the patient can be fed orally. Generally, the

antibiotic switch can take place after 2-4 days of

intravenous therapy.32

There is no appropriate randomized study to define

the optimal duration of antibiotic therapy for CAP. Most

recommendations are conjectural, and many physicians

recommend treatment for 1-2 weeks.32The recommended

durations of treatment in this guideline are based on the

experiences of experts and some statements in textbooks.

Seven to 10 days of treatment is usually enough with

2 exceptions. One is Legionnaires' disease that may

be more severe than other causes of atypical pneumonia,

especially when it occurs in immunocompromised children.

The recommended duration is longer. The other is

complicated pneumonia that may require a longer duration

of treatment, including those complicated by bacteremia

or meningitis, Pseudomonas aeruginosa infection,empyema, necrotizing pneumonia, and lung abscess.

Community-acquired P. aeruginosa sepsis with or

without pneumonia is most frequently seen in infants.48One study showed that 8-day therapy forP. aeruginosa

pneumonia led to relapse more commonly than did 15-

day therapy.49

When the pathogen is known, the antibiotic should

be chosen according to the antibiotic susceptibility pattern.

Antibiotic resistance among pneumococci is increasing

and the incidence of severe pneumococcal pneumonia

is apparently increasing in recent years.50Being the same

as our previous version of guideline,51 a penicillin

minimum inhibitory concentration (MIC) of < 1 g/mLwas defined as penicillin susceptible, MIC 4 g/mL

as penicillin resistant, and an intermediate MIC as

penicillin intermediate. Recently, penicillin MIC's

of about 70% of S. pneumoniae strains in Taiwan

are 0.12 g/mL, while only less than 5% is penicillin-

resistant (MIC 4 g/mL).52Therefore, most penicillin-

nonsusceptible S. pneumoniaeinfection can be treated

by a high dose of penicillin and its analogue. On the

other hand, erythromycin resistance in S. pneumoniae

has remained high (94%) in Taiwan in recent years.52

Likewise, trimethoprim-sulfamethoxazole resistance rate

is also high (65%).53

Recent studies in Taiwan showed that 56% of H.influenzaeisolates produce -lactamase, as did nearly

all Moraxella catarrhalis isolates (95.7%). Only

1.7% ofH. influenzaewere -lactamase negative and

amoxicillin resistant.53Antibiotics used for these gram-

negative bacteria should be stable to -lactamase. The

resistance rate to trimethoprim-sulfamethoxazole is 52%

for H. influenzae.53

Having being a predominant pathogen in nosocomial

infections in Taiwan for many years, methicillin-resistance

S. aureusis now becoming more and more common


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in community-acquired infections. Recent data

demonstrated that 50-70% of community strains of S.

aureusobtained from pediatric patients is resistant to

methicillin.12,13 Vancomycin and other agents active

against methicillin-resistance S. aureus may be considered

in selected cases, especially for those with chest trauma

and influenza.54

M. pneumoniae, C. pneumoniaeand C. trachomatis

are rarely resistant to erythromycin and other macrolides

that should be the drug of choice for these infections.

Different macrolides have similar therapeutic efficacy.6Tetracyclines may be used as an alternative only when

the child is older than 8 years to avoid their potential

detrimental effects on bone and teeth. Although

fluoroquinolones may be used as the first-line drug for

treatingL. pneumophila infection,32,55new macrolides

are a more preferred agent in children. Rifampin or

fluoroquinolones may be added in severe infections.When the pathogen is unknown, either before the

culture result is available or due to a negative result of

microbiological test, antibiotics may be given empirically

based on the knowledge of predominant pathogens in

each age groups.

For neonates younger than 1 month, Escherichia

coli, group B streptococcus and other bacteria are

common pathogens. They may be treated empirically

by ampicillin + aminoglycosides, or by ampicillin +

cefotaxime or ceftriaxone when meningitis is a concern.

Common bacterial pathogens of CAP in children between

2 months and 5 years of age include S. pneumoniae

andH. influenzaetype b. -lactams stable to -lactamasemay be used empirically. S. pneumoniaebecomes the

single most important etiology of CAP in children beyond

6 years of age. Penicillin may be used as empirical therapy

for clinically stable patients.

M. pneumoniaeand C. pneumoniae infections are

not infrequent after 2 years of age.6,7For children older

than 2 years with suspected atypical pneumonia,

macrolides are the antibiotic of choice. However, such

infections are not totally absent in children younger than

2 years,6and C. trachomatisis a possible etiology of

CAP in infants.8Macrolide antibiotics may be used in

special circumstances.

The choice of antibiotics should also take into accountthe severity of illness and comorbidities. Several

guidelines for management of CAP in adults stratify

patients into groups based on site of therapy (i.e.

outpatient, inpatient, or intensive care unit),

comorbidities (including cardiopulmonary disease,

diabetes mellitus, renal failure, malignancy), and risk

factors for infection with drug-resistant bacteria.32,55,56

To avoid too many stratifications, the working group

choose to stratify pediatric patients by the age only.

However, some points deserve further attention.

A few retrospective studies suggested that dual

therapy with -lactams and a macrolide may reduce

mortality associated with bacteremic pneumococcus

pneumonia. 57,58 Two possible explanations are the

immunonodulating effect of macrolides and a concomitant

infection by atypical pathogens that may be susceptible

to macrolides. A well-designed prospective study is

needed to prove such an observation, and the data in

pediatric patients are still lacking. However, adding

a macrolide for children with suspected pyogenic

pneumonia may be warranted since mixed infections are

not uncommon in children with CAP.

With life-threatening complications, such as sepsis

and meningitis, CAP in children may be treated

empirically with broad-spectrum and potent antibiotics,

such as vancomycin plus a third-generation cephalosporin

or other antibiotics effective against commonly seen gram-

negative bacteria.Enteric gram-negative bacteria, such asP. aeruginosa,

may pose some impact on selection of an appropriate

antibiotic for treatment of CAP. Several risk factors have

been recognized in adult patients.56Patients who reside

in a nursing home, or have underlying cardiopulmonary

disease or multiple comorbidities, or have received recent

antimicrobial therapy are more likely to be infected by

enteric organisms. Risk factors for P. aeruginosa

infection include structural lung disease (e.g.

bronchiectasis), steroid therapy, recent use of broad-

spectrum antibiotic, and malnutrition. Although similar

data are lacking for children, the working group makes

similar recommendations. When children with disorderssuch as bronchiectasis, chronic lung disease, and severe

neuromuscular disorders have a history of recurrent

pneumonia, repetitive use of antibiotics, or prolonged

use of steroids, they tended to be infected by gram-

negative bacteria, including P. aeruginosa. Empiric

therapy may include antipseudomonal -lactams

(including ceftazidime, piperacillin, ticarcillin/clavulanate,

piperacillin/tazobactam, cefepime, imipenem, and

meropenem) with or without aminoglycosides.

Because some antibiotic-resistant bacteria, especially

penicillin-nonsusceptible S. pneumoniae, are highly

prevalent in Taiwan, the dosage of some antibiotics should

be modified. As mentioned before, less than 5% ofpenicillin-nonsusceptible S. pneumoniae is truly resistant

to penic il lin with a MIC 4 g/mL in Taiwan,52

increasing the dose of penicillin, ampicillin, amoxicillin,

ampicillin/sulbactam, amoxicillin/clavulanate, cefuroxime,

and cefotaxime may be an effective way to treat infections

caused by penicillin-intermediate S. pneumoniae. The

recommended dosage of various antibiotics in present

guideline is for empirical use of antibiotics. The dosage

of antibiotics may be adjusted when the pathogen and

its antibiotic susceptibility pattern are known. For


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example, when dealing with penicillin-susceptible S.

pneumoniae infection, the dose of penicillin may be

lowered down.

As suggested by recent pharmacokinetic and

pharmacodynamic studies, some antibiotics are time-

dependent for their therapeutic effect, including -lactams

and macrolides. Frequent dosing may improve their

performance. On the other hand, Some antibiotics are

concentration-dependent, including aminoglycosides and

fluoroquinolones. Such antibiotics should be given with

a longer dosing interval to maximize their therapeutic

effect.59In the era of increasing resistance, an dosing

schedule with optimized pharmacokinetic and

pharmacodynamic features can not only bring about a

better treatment response, but also prevent the emergence

of resistant bacteria. The recommended dosage in this

guideline was set up according to this principle.

VI. POST-TREATMENT EVALUATION AND

MANAGEMENT OF COMPLICATION

A. If the fever persists, the clinical condition is not

improved, or aggravating signs appeared after

treatment, the following conditions should be

considered.

1. Inadequate dose of antibiotics.

2. Antimicrobials not effective for offending pathogen,

such as antibiotic-resistant bacteria, tuberculosis.

3. Viral infection or mixed infection.

4. Extrapulmonary focus of infection.5. Complication of pneumonia, such as lung abscess,

empyema.

6. Drug fever.

B. Complication of pneumonia:

1. Pleural effusion, empyema.

2. Necrotizing pneumonia, lung abscess.

3. Acute respiratory distress syndrome.

4. Others, such as bronchopleural fistula.

C. Management of pleural effusion and empyema:

1. Diagnosis: lateral decubitus chest radiography or

chest ultrasonography. The latter is preferred.

2. Pleural tapping: Examinations of pleural fluid should

include white count and differentials, pH value,glucose, protein, gram stain, acid-fast stain,

bacterial culture, mycobacteria culture. Bacteria

antigen detection may also be considered.

3. With one of the following conditions, drainage

of pleural fluid should be required:

a. Pus-like effusion.

b. Positive finding of gram stain or bacterial culture

of pleural fluid.

c. Large amount of fibrinous substances or septations

in pleural cavity.

d. Massive pleural effusion associated with

respiratory distress.

e. pH of pleural fluid < 7.2.

4. Draining procedure

a. Simple chest tube drainage: not recommended.

b. Chest tube drainage with firbrinolytic agents: Use

streptokinase 2,500 U/mL or urokinae 1,000 U/

mL with a dose of 3-4 mL/kg that does not exceed

100 mL. The agent may be given once per day

with retention of the agent for 2-4 hours each

time. The therapy may be instituted for 2-3 days

or until there is a significant improvement of chest

images. Tissue plasminogen activator may be

used with a dose of 2-5 gm in 50-250 mL saline.

c. Video-assisted thoracoscopic surgery (VATS):

Computerized tomography of the chest should

be per formed previous to this procedure to

delineate the extent of pleural effusion. EarlyVATS that is performed within 4 days after the

diagnosis is more effective than late VATS.

d. If the above mentioned draining procedures fail

to improve the condition, such as persistent high

fever and severe respiratory distress, open surgery

for drainage may be considered.

D. Management of necrotizing pneumonia and lung

abscess: Chest ultrasonography or computerized

tomography should be performed. If the clinical

condition does not improve after appropriate

antimicrobial therapy and drainage, open surgery may

be considered.

If the fever persists, the clinical condition is not

improved or even aggravated after treatment, several

possibilities should be considered.60Because penicillin-

nonsusceptible S. pneumoniae is highly prevalent in

Taiwan,50,52an adequate dose of antibiotics as mentioned

in present guideline is a prerequisite to ensure treatment

success. For young infants and children with risk factors,

antibiotics with a broader antibacterial spectrum may be

necessary to be effective against potential pathogens,

including methicillin-resistant S. aureus10,11and enteric

gram-negative bacteria.56As mentioned previously, M.

tuberculosisinfection is prevalent in Taiwan and should

be regarded as a possible etiology in CAP unresponsiveto empiric antibiotic therapy.15

Viral infection and extrapulmonary focus of infection

are also possible causes for an unresponsive CAP. A

study in Taiwan showed that children with a severe

pneumonic change (consolidation or pleural effusion)

or extrapulmonary manifestations (e.g. encephalitis,

hepatitis) tended to have a prolonged fever after

appropriate macrolide treatment in children with either

M. pneumoniaeor C. pneumoniaeinfection.6Adequate

drainage of lung abscess and empyema may be necessary


11/14


for some complicated pneumonia.

Drug fever is easily overlooked because affected

patients may have an extremely high temperature and

a high CRP value. Sulfonamides and -lactams are

common causes of drug fever. However, it should be

assumed that any drug can cause drug fever, including

nonantibiotics.60Fever may developed a few days after

using an antibiotic.61A relatively good activity with

re-emergence of fever after defervescence for some days

after treatment is characteristic for drug fever. Other

helpful clues to drug fever are skin rashes, relative

bradycardia , neutropenia, eos inophilia, atypical

lymphocytosis, elevations of the serum transaminases.61,62The diagnosis of drug fever may be confirmed by

observing a subsidence of fever after withholding the

offending medication. Drug fever usually subsides within

72 hours after the sensitizing drug is discontinued if a

rash is not present.

61

Parapneumonic pleural effusion is not uncommon

in children with bacterial pneumonia and is a common

cause of prolonged fever after treatment. A study in

Taiwan showed that 56% of pneumococcus pneumonia

in children is complicated.50It has been recommended

that for all adult patients with acute bacterial pneumonia,

the presence of a parapneumonic effusion should be

considered.63The effusion may be delineated by lateral

decubitus chest radiography or by chest ultrasonography.

Chest ultrasonography is preferred because it is more

accurate relative to lateral decubitus chest radiography

for the diagnosis of small pleural effusions.64

Aspirated pleural fluid should be sent for necessarytests. Some studies showed that commercially available

pneumococcal antigen test that was designed for

cerebrospinal fluid samples may also be useful for pleural

fluid.65,66Although available data are limited, the working

group suggests that such a bacteria antigen test may be

used for pleural fluid when S. pneumoniae infection

is one of the possible pathogen.

It is a common agreement that a frankly purulent

effusion or an effusion containing bacteria as evidenced

by either culture or gram stain should be drained to hasten

the recovery and to avoid complications. Dilemma occurs

when the effusion does not appear purulent. A meta-

analysis suggested that a low pH < 7.21-

7.29 was the

most accurate predictor of the need for drainage.67The

cut-off point for pH is controvers ial. The present

recommendation adopts a pH of 7.2 as a cut-off, similar

to that recommended by the American College of Chest

Physicians.63

There are several drainage procedures. A recent

review showed that the pooled mortality was higher for

the no drainage (6.6%), therapeutic thoracentesis (10.

3%), and tube thoracostomy (8.8%) than for the

fibrinolytic (4.3%), VATS (4.8%), and surgery (1.9%).

The pooled proportion of patients needing a second

intervention was also higher for the no drainage,

therapeutic thoracentesis, and tube thoracostomy

management approaches.63

Adding streptokinase, urokinase or tissue plasminogen

activator into the chest cavity may facilitate the drainage

by causing lysis of fibrins and septations. Fibrinolytic

agents are resolved in normal saline that is instituted into

a properly positioned chest tube. The drainage is held

for several hours for firbrinolytic agents to take effect.

Several studies in Taiwan have shown that intrapleural

fibrinolytic treatment is safe and effective in children,

and it can obviate the need for surgery.68,69There is not

a consensus on the dosage of firbrinolytic agents.

However, the working group suggests one dosage

schedule according to the experience in Taiwan.

Most studies agree that debridement of the pleuralspace by VATS is effective for the management of pleural

empyema, including studies in children. Data also

suggested that the main prognostic factor for thoracoscopic

treatment of pleural empyema is the interval between

diagnosis and surgery.70,71A 4-day limit, corresponding

to the natural process of empyema organization, may

significantly affect the efficacy of VATS.70,72Therefore,

VATS should be attempted within 4 days after diagnosis

when necessary. Open surgery is another option for the

treatment of pleural empyema in children.

Necrotizing pneumonia and lung abscess are not

uncommon in children with CAP. Diagnosis may be

confirmed by ultrasonography or computerizedtomography. Prolonged antibiotic therapy may be required.

Infrequently, open surgery may be needed in complicated

cases refractory to medical therapy.

VII. PREVENTION

A. General principles: reduce the risk of exposure to

respiratory pathogens by droplet precautions.

B. Immunization:

1. Bacille Calmette-Gurin vaccine: routine for all

neonates and 7-year-old children who has a negative

tuberculin reaction.2. Influenza vaccine:

a. Routine for children aged 6-23 months.

b. Recommended for children older than 23 months

with high-risk conditions.

3. Pneumococcal vaccine: 23-valent pneumococcal

polysaccharide vaccine (PPV23) for children older

than 2 years and 7-valent pneumococcal conjugate

vaccine (PCV7) for children older than 2 months.

Recommended schedule for those having not

received pneumococcal vaccines:


12/14


C. Preventive therapy:

1. Tuberculosis: isoniazid 10 mg/kg/day (maximum

300 mg/day) for 9 months recommended for children

12 years with evidence of latent tuberculosis

infection and a history of close contact with patients

with infectious tuberculosis.

2.Haemophilus influenzaetype b infection: rifampin

20 mg/kg (maximum 600 mg) daily for 4 days for

all household contacts when at least 1 contact is

younger than 4 years of age.

Pathogens responsible for CAP are transmitted by

droplet, while most bacterial pneumonia may be

complications of some preceding virus infection.73

Preventive measures for CAP include droplet precautions

for hospitalized children, strict hand hygiene procedures,

and that infected children should be excluded from school

and day care facilities until they are no longer considered

contagious.

According to the guidelines for the diagnosis andtreatment of tuberculosis in Taiwan, one dose of BCG

should be given to all neonates with a body weight

2,500 gm. Tuberculin skin test is done at school entry

(7 years of age) for children whose BCG scar is 2 mm

in diameter. One dose of BCG should be given to those

who have a negative tuberculin reaction.

Currently, influenza vaccine is a routine for children

aged between 6 and 23 months in Taiwan. The vaccine

is also recommended for children older than 23 months

of age with risk factors, including chronic pulmonary

diseases (e.g. bronchopulmonary dysplasia, cystic

fibrosis, bronchiolitis obliterans, laryngotracheomalasia,

asthma), hemodynamically significant cardiac disease,immunosuppresive disorders or therapy, human

immunodeficiency virus infection, hemoglobinopathies,

disorders requiring long term salicylate therapy (e.g.

rheumatoid arthritis, Kawasaki disease), chronic renal

dysfunction, chronic metabolic disease (including diabetes

mellitus), and any condition that can compromise

respiratory function or handling of respiratory tract

secretions or that can increase the risk of aspiration.74

Two pneumococcal vaccines are available in Taiwan,

including a 23-valent polysaccharide pneumococcal

vaccine (PPV23) for use in children aged over 2 year,

and a 7-valent pneumococcal conjugate vaccine (PCV7)

for children between 2 months and 9 years of age. The

PCV7 is recommended for routine vaccination at 2, 4,

6, and 12-18 months of age. Catch-up vaccination is

also recommended for children up to 23 months of age

with fewer doses of PCV7. The cost-effectiveness of

pneumococcal vaccines in healthy children between 24

and 59 months of age remain to be studied. Pneumococcal

vaccines may be given to all children older than 24

months of age with risk factors, including

hemoglobinopathies, congenital or acquired immune

deficiency, human immunodeficiency virus infection,

chronic pulmonary disease, chronic renal disorders,

diabetes mellitus, anatomical abnormalities associated

with higher rates or severity, cerebrospinal leaks,

hemodynamically significant heart disease, and chronic

pulmonary disease.75

Recent revision of the guidelines for the diagnosisand treatment of tuberculosis in Taiwan recommends that

isoniazid chemoprophylaxis may be given to children

12 years with evidence of latent tuberculosis infection

by the tuberculin reaction and a history of close contact

with patients with infectious tuberculosis. The risk of

invasive Haemophilus inf luenzae type b disease is

increased among household contacts who are less than

4 years of age. Rifampin 20 mg/kg (maximum 600 mg)

daily for 4 days is recommended for all household

contacts in such occasions regardless of the age of

household contacts and theHaemophilus influenzaetype

b vaccination history.

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