Guidelines for the management

of community acquired

pneumonia in children

Khaled Saad ZaghloulM D. Pediatrics

Children are “SPECIFIC patients”,

and not “small ADULTS

*Guideline objectives:

• To improve the use and interpretation of

clinical signs and symptoms.

• To improve the appropriate use of

diagnostic testing.

• To improve the rate of hospitalized

patients who meet admission criteria.

• To improve the use of appropriate

antibiotic therapy.

Target Population

• These guidelines are intendedprimarily for use in children 30days through 18 years of age withsigns, symptoms, or other findingss u g g e s t i n g a d i a g n o s i s o fpneumonia acquired by exposureto organisms in the community.

Main points:

• Diagnosis/Evaluation

• Management

• Prevention

• Treatment

Diagnosis/Evaluation:

• Clinical assessment: including

initial history & physical

examination: It is recommended

that the initial history include:

age of child, season of the year,

immunization status, exposure to

tuberculosis.

• Physical examination performed for signs of respiratory illness and fever, use of the World Health Organization age-specific criteria for tachypnea, and assessment of severity based on overall appearance and behavior.

• Bacterial pneumonia should be considered in children when there is persistent or repetitive fever >38.5C together with chest recession and a raised respiratory rate. D

Signs of Respiratory Distress

1.Tachypnea, respiratory rate, breaths/min

Age 0–2 months: >60

Age 2–12 months:>50

Age 1–5 Years:>40

Age>5 Years: >20

2. Dyspnea

3. Retractions (suprasternal, intercostals, or subcostal)

4. Grunting

5. Nasal flaring

6. Apnea

7. Altered mental status

8. Pulse oximetry measurement <90% on room air

Indications for admission of Children with Pneumonia

Age <6 months

Multiple lobe involvement

Immunocompromised state

Toxic appearance

Severe respiratory distress, see previous table and

hypoxemia (sustained saturation of peripheral oxygen

[SpO2] <90 %.

Requirement for supplemental oxygen

Dehydration, Vomiting

Sickle cell anemia with acute chest syndrome

No response to appropriate oral antibiotic therapy &

Noncompliant parents.

Radiologic Assessment:

• chest x ray done selectively; chest radiographs (posteroanterior and lateral) should be obtained in all patients hospitalized for management of CAP to document the presence, size, and character of parenchymal infiltrates and identify complications of pneumonia that may lead to interventions beyond antimicrobial agents and supportive medical therapy.

• Children with signs and symptoms of

pneumonia who are not admitted to

hospital should not have a chest x-ray. A-

• A lateral x-ray should not be performed

routinely. B-

• Chest radiography should not be

considered a routine investigation in

children thought to have community

acquired pneumonia (CAP). A-

• Repeated chest radiographs should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration within 48–72 hours after initiation of antibiotic therapy.

• Follow-up chest radiographs should be obtained in patients with complicated pneumonia with worsening respiratory distress or clinical instability, or in those with persistent fever that is not responding to therapy over 48-72 hours.

Laboratory tests:

• Done selectively (A complete blood cell count should be obtained for patients with severe pneumonia , sputum Gram stain and culture, pleural culture, tuberculin test and other tests in children with a history of exposure to tuberculosis, and additional studies as appropriate)

• Acute phase reactants are not of clinical utility in distinguishing viral from bacterial infections and should not be tested routinely. [A-]

• C reactive protein is not useful in the management of uncomplicated pneumonia and should not be measured routinely. [A+]

• Microbiological diagnosis should be attempted in children with severe pneumonia sufficient to require pediatric intensive care admission, or those with complications of CAP. [C]

• Microbiological investigations should not be considered routinely in those with milder disease or those treated in the community. [C]

• Microbiological methods used should include: Blood culture. [C] , Naso-pharyngeal secretions and/or nasal swabs for viral detection by PCR. [C]

• Bronchoscopic specimen brush sampling, bronchoalveolar lavage (BAL), percutaneous lung aspiration, or lung biopsy should be reserved for the immunocompetent child with severe CAP if initial diagnostic tests are not positive.

Etiology of severe pneumonia in

children in developing countries

AGE

GROUP FREQUENT PATHOGENS (IN ORDER OF FREQUENCY)

1–3 mo

Febrile

pneumonia

Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses,

influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b,

nontypable)

Afebrile

pneumonia

Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum,

cytomegalovirus

3–12 mo Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses,

influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b,

nontypable), C. trachomatis, Mycoplasma pneumoniae, group A streptococcus

2–5 yr Respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses), S.

pneumoniae, H. influenzae (type b, nontypable), M. pneumoniae,

Chlamydophila pneumoniae, S. aureus, group A streptococcus

5–18 yr M. pneumoniae, S. pneumoniae, C. pneumoniae, H. influenzae (type b,

nontypable), influenza viruses, adenoviruses, other respiratory viruses

≥18 yr M. pneumoniae, S. pneumoniae, C. pneumoniae, H. influenzae (type b,

nontypable), influenza viruses, adenoviruses, Legionella pneumophila

Etiologic Agents Grouped by Age of the Patient

DD viral & bacterial pneumonia in childhood:

Treatment/Management

1- Antibiotic treatment :

• All children with a clear clinical diagnosis of

pneumonia should receive antibiotics as bacterial

and viral pneumonia cannot reliably be

distinguished from each other.

• ** Amoxicillin, co-amoxiclav, oral second- or

third-generation cephalosporins (cefpodoxime,

cefuroxime, and cefprozil), is recommended as

first choice for oral antibiotic therapy in all

children because it is effective against the

majority of pathogens which cause CAP.

Note1 : Because Mycoplasma pneumoniae or

Chlamydia (Chlamydophila) pneumoniae are a

less common cause of CAP in children under age

5 years, macrolides are not considered first line

therapy. A macrolide could be added to

amoxicillin therapy at the 24 to 48 hour follow

up if M. pneumoniae or C. pneumoniae is then

suspected. This practice will avoid overuse of

macrolides in this age group while adequately

protecting the young child from resistant S.

pneumoniae.

Note 2: For an infant or child unable to tolerate

liquids, a single initial dose of ceftriaxone may be

considered prior to starting oral antibiotics.

Note 3: It is recommended, in a child with a more

severe case of CAP, that the combination of both

a macrolide and a beta-lactam agent (such as

high dose amoxicillin or ceftriaxone) be

considered. This will provide better coverage for

resistant organisms and mixed infections.

** In pneumonia associated with influenza,

co-amoxiclav is recommended.

** Intravenous antibiotics should be used

in the treatment of pneumonia in children

when the child is unable to tolerate oral

fluids or absorb oral antibiotics (eg,

because of vomiting) or presents with

signs of septicemia or complicated

pneumonia.

** Recommended intravenous antibiotics

for severe pneumonia include amoxicillin,

co-amoxiclav, cefuroxime and cefotaxime

or ceftriaxone. These can be rationalized

if a microbiological diagnosis is made.

** In a patient who is receiving intravenous

antibiotic therapy for the treatment of

CAP, oral treatment should be considered

if there is clear evidence of improvement.

Pathogen Parenteral therapy Oral therapy (step-down therapy

or mild infection)

Streptococcus

pneumoniae

sensitive to

penicillin

Preferred: ampicillin (150–200 mg/kg/day

every 6 hours) or penicillin (200 000–250 000

U /kg /day every 4–6 h);Alternatives:

ceftriaxone

(50–100 mg/kg/day every 12–24 hours)

(preferred for parenteral outpatient therapy) or

cefotaxime (150 mg/kg/day every 8 hours);

clindamycin (40 mg/kg/day every 6–8 hours)

or vancomycin (40–60 mg/kg/day

every 6–8 hours)

Preferred: amoxicillin (90 mg/kg/day in 2 doses

or 45 mg/kg/day in 3 doses);

Alternatives: second- or third-generation

cephalosporin (cefpodoxime, cefuroxime,

cefprozil); oral levofloxacin,(16–20 mg/kg/day

in 2 doses for children

6 months to 5 years old and 8–10 mg/kg/day

once daily for children 5 to 16 years old;

maximum daily dose, 750 mg) or oral linezolid

(30 mg/kg/day in 3 doses for children ,12 years

old and 20 mg/kg/day

in 2 doses for children >12 years old)

S. pneumoniae

resistant to

penicillin

Preferred: ceftriaxone (100 mg/kg /day every

12–24 hours);

Alternatives: ampicillin (300–400 mg /kg/day

every 6 hours), levofloxacin

(16–20 mg/kg/day every 12 hours for children

6 months to 5 years old and 8–10 mg/kg/day

once daily for children 5–16 years old;

maximum daily dose, 750 mg), or linezolid

(30 mg/kg/day every 8 hours for children ,12

years old and 20 mg/kg/day every 12 hours

for children >12 years old); may also be

effective: clindamycin (40 mg/kg/day every

6–8 hours) or vancomycin (40–60 mg/kg/day

every 6–8 hours)

Preferred: oral levofloxacin (16–20 mg/kg/day

in 2 doses for children 6 months to 5 years and

8–10 mg/kg/day once daily for children 5–16

years, maximum daily dose, 750 mg), if

susceptible, or oral linezolid (30 mg/kg/day in 3

doses for children ,12 years and 20 mg/kg/day in

2 doses for children >12 years);

Alternative: oral clindamycin

(30–40 mg/kg/day in 3 doses)

Selection of Antimicrobial Therapy for Specific Pathogens:

Pathogen Parenteral therapy Oral therapy (step-down

therapy

or mild infection)

Group A

Streptococcus

Preferred: intravenous penicillin (100

000–250 000 U/kg/day every 4–6 hours)

or ampicillin (200 mg/kg/day every 6

hours);

Alternatives: ceftriaxone (50–100 mg/kg

/day every 12–24 hours) or cefotaxime

(150 mg/kg/day every 8 hours);

clindamycin, (40 mg/kg/day every 6–8

hours) or vancomycin (40–60 mg/kg/day

every 6–8 hours)

Preferred: amoxicillin (50–75 mg/kg/day in

2 doses), or penicillin V (50–75 mg/kg/day

in 3 or 4 doses);

Alternative: oral clindamycin

(40 mg/kg/day in 3 doses)

Stapyhylococcu

s aureus,

methicillin

susceptible

Preferred: cefazolin (150 mg/kg/day

every 8 hours) or semisynthetic

penicillin, eg oxacillin (150–200

mg/kg/day every 6–8 hours);

Alternatives: clindamycin (40 mg/kg/day

every 6–8 hours) or >vancomycin (40–60

mg/kg/day every 6–8 hours)

Preferred: oral cephalexin (75–100

mg/kg/day in 3 or 4 doses);

Alternative: oral clindamycin

(30–40 mg/kg/day in 3 or 4 doses)

Pathogen Parenteral therapy Oral therapy (step-down

therapy

or mild infection)S. aureus,

methicillin

resistant

Preferred: vancomycin (40–60

mg/kg/ day every 6–8 hours or

dosing to achieve an AUC/MIC

ratio of .400) or clindamycin (40

mg/kg/day every 6–8 hours);

Alternatives: linezolid (30

mg/kg/day every 8 hours for

children ,12 years old and 20

mg/kg/day every

12 hours for children >12 years

old)

Preferred: oral clindamycin (30–40

mg/kg/day in 3 or 4 doses);

Alternatives: oral linezolid

(30 mg/kg/day in 3 doses for

children

,12 years and 20 mg/kg/day in 2

doses

for children >12 years)

S. aureus,

methicillin

resistant,

resistant to

clindamycin

Preferred: vancomycin (40–60

mg/kg/ day every 6-8 hours

Alternatives: linezolid (30

mg/kg/day every 8 hours for

children ,12 years old and 20

mg/kg/day every 12 hours for

children >12 years old)

Preferred: oral linezolid (30

mg/kg/day in

3 doses for children ,12 years and

20 mg/kg/day in 2 doses for children

>12 years old);

Pathogen Parenteral therapy Oral therapy (step-down

therapy

or mild infection)

Haemophilus

influenza

intravenous ampicillin (150-200

mg/kg/day every 6 hours) if b-

lactamase negative, ceftriaxone

(50–100 mg/kg/day every 12-24

hours) if b-lactamase producing,

or

cefotaxime (150 mg/kg/day

every 8 hours

amoxicillin (75-100 mg/kg/day in 3 doses) if b-

lactamase negative) or

amoxicillin clavulanate (amoxicillin

component, 45 mg/kg/day in 3 doses or 90

mg/kg/day in 2 doses) if b-lactamase producing;

Alternatives: cefdinir, cefixime, cefpodoxime, or

ceftibuten

Mycoplasma

pneumoniae/

Chlamydia

Preferred: intravenous

azithromycin

(10 mg/kg on days 1 and 2 of

therapy;

transition to oral therapy if

possible);

Preferred: azithromycin (10 mg/kg on day 1,

followed by 5 mg/kg/day once daily on

days 2–5);

Alternatives: clarithromycin

(15 mg/kg/day in 2 doses) or oral

erythromycin (40 mg/kg/day in 4 doses);

for children .7 years old, doxycycline

(2–4 mg/kg/day in 2 doses; for adolescents

with skeletal maturity, levofloxacin

(500 mg once daily) or moxifloxacin

(400 mg once daily)

2) Appropriate Duration of Antimicrobial

Therapy for CAP: Treatment courses of 10

days have been best studied, although shorter

courses may be just as effective, particularly for

more mild disease managed on an outpatient

basis.

3) Infections caused by certain pathogens, notably

S. aureus, methicillin resistant may require

longer treatment than those caused by S.

pneumoniae.

Prevention and Education:

It is recommended that immunizations which

prevent CAP be kept up-to-date, including:

heptavalent conjugated pneumococcal vaccine

(PCV7, Prevnar®), and annual influenza

vaccine for all children 6 to 23 months of age,

and children aged >6 months with certain risk

factors (including but not limited to asthma,

cardiac disease, sickle cell disease, human

immunodeficiency virus [HIV] and diabetes)

• It is recommended that measures to

prevent pneumonia infections be discussed

with families, including:

– hand washing, especially when exposed to

individuals with respiratory infections

– breastfeeding

– limiting exposure to other children with

respiratory infections

– Reducing exposure to smoke