Pediatric Pneumonia in the ED: How to Diagnose and Treat?

Dr. Tim Lynch

June 4, 2012

Conflict of InterestConflict of Interest• NilNil

Learning ObjectivesLearning ObjectivesAt the end of this session participants:p p

• 1.) will have reviewed an evidence-based approach to the diagnosis and management of pediatric pneumoniat e d ag os s a d a age e t o ped at c p eu o a

• 2.) will have reviewed new clinical practice guidelines for the diagnosis and management of pediatric pneumoniathe diagnosis and management of pediatric pneumonia

• 3.) will have reviewed atypical presentations and complications that may pose a challenge to the cliniciancomplications that may pose a challenge to the clinician

Burden of DiseaseBurden of Disease• Pneumonia is the single greatest cause ofPneumonia is the single greatest cause of

death in children worldwide

E h 2 illi hild th 5• Each year >2 million children younger than 5 years die of pneumonia, representing 20% of all deaths in children within this age groupall deaths in children within this age group

• Word Pneumonia Day – November 12, 2012

ObjectivesObjectives• Introduction

• Epidemiology

• Diagnosis – evidence-based

• New Guidelines

• Complications

• Treatment – evidence-based

• Take Home MessageTake Home Message

PopulationPopulation• Management of:Management of:

– neonates and infants less than 3 months,– Immunocompromised,– those receiving home mechanical ventilation,– And those with chronic conditions or underlying lung disease ‐ cystic fibrosis

IntroductionIntroduction• Common clinical entityCommon clinical entity

• Overall incidence:

• 4 % per year < 5 years• 2% 5‐9 yearsy• 1% > 9 years

IntroductionIntroduction• Inflammation of the lung tissue postInflammation of the lung tissue post

noninfectious or infectious insult

A t i f ti f th l i t t t• Acute infection of the lower respiratory tract parenchyma

– Viral – increased risk of secondary bacterial– Bacterialac e a– Atypical

IntroductionIntroduction• Community acquired pneumonia (CAP) canCommunity acquired pneumonia (CAP) can

be defined clinically as:

• the presence of signs and symptoms of pneumonia in a previously healthy child due to an infection which has been acquired outside hospital.q p

EtiologyEtiology• ViralViral

• RSV, influenza – seasonal• Parainfluenza 1 and 3• Adenovirus• Metapneumovirus• Metapneumovirus

EtiologyEtiology• Bacterial and Atypical:Bacterial and Atypical:

• 3 months to 5 years – S.pneumoniae, S.aureus

• 5 years to 18 years – S.pneumoniae, M.pneumoniae

Accurate EtiologiesAccurate Etiologies• Extrapolate from hospitalized patientsExtrapolate from hospitalized patients

Etiological Diagnosis of Childhood Pneumonia by Use of Transthoracic Needle Aspiration and Modern Microbiological MethodsMethodsVuori-Holopaine, E et al Clin Infect Dis 2002;34:583-590.

• Aspiration disclosed the etiology in:Aspiration disclosed the etiology in:

– 20 of 34 cases overall (59%)

• Pneumothorax developed in:Pneumothorax developed in:

– 6 patients (18%)

Epidemiology and Clinical Characteristics of Community-Acquired Pneumonia in Hospitalized ChildrenAcquired Pneumonia in Hospitalized ChildrenMichelow, I et al Pediatrics 2004;113:701-707

• 154 children (2 mo – 17 y) with lower154 children (2 mo 17 y) with lower respiratory tract infections:

• 80 % had pathogen identified– 60 % bacterial – 75 % pneumococcus– 45 % viral– 15 % Mycoplasma pneumoniae– 10 % Chlamydia pneumoniae23 % Mixed bacterial/viral– 23 % Mixed bacterial/viral 

Epidemiology and Clinical Characteristics of Community-Acquired Pneumonia in Hospitalized ChildrenpMichelow, I et al Pediatrics 2004;113:701-707

• Those with bacterial and mixed LRI’s had theThose with bacterial and mixed LRI s had the greatest degree of inflammation and severity

– High temperatures– Pleural effusions– Elevated procalcitonin, bands– Assisted ventilation– Prolonged hospitalization

Epidemiology and Clinical Characteristics of Community-Acquired Pneumonia in Hospitalized ChildrenpMichelow, I et al Pediatrics 2004;113:701-707

• Those with M and C pneumoniae:Those with M and C pneumoniae:

• As common in pre‐schoolers as older children

Diagnosis of PneumoniaDiagnosis of Pneumonia• What is your gold standard?What is your gold standard?

Clinical SymptomsClinical Symptoms• Fever, cough, poor feeding, difficultyFever, cough, poor feeding, difficulty

breathing, vomiting

Ch t bd i l i• Chest, abdominal pain

• Persistent coughg

Clinical SignsClinical Signs• TachypneaTachypnea

• Dullness, tactile fremitus, reduced vesicular, i d b hi lincreased bronchial

• Wheeze

TachypneaTachypnea• Tachypnea is a nonspecific clinical signTachypnea is a nonspecific clinical sign

• may be a marker for respiratory distress and/or h ihypoxemia.

• fever, dehydration, or a metabolic acidosis 

WHO DiagnosisWHO Diagnosis• Tachypnea and retractions are the mostTachypnea and retractions are the most

accurate signs for identifying pneumonia

• > 50 breaths/min in infants 2 to 12  months of age,• > 40 breaths/min in children aged 1 to 5 years, and• > 20 breaths/min in children aged 5 years and older• > 20 breaths/min in children aged 5 years and older

InvestigationsInvestigations• Chest RadiographChest Radiograph

• Pathogen Detection

• Blood Tests

Estimates of radiation dosage delivered fromdi ti icommon diagnostic images

Procedure Average Effective Dose  Equivalent natural (mSv) background radiation 

(months)

Plain Film

Chest PA 0.02‐0.05 0.14

Chest PA and Lateral 0.1 0.3

Extremity 0.1 0.3y

Abdomen 1.0 2.9

Pelvis 1.6 4.6

Computed TomographyComputed Tomography

Head 2.0 5.7

Chest  7.0 20

Abdomen 9.0 25.7

Chest RadiographChest Radiograph– Otherwise overdiagnosedOtherwise overdiagnosed– Helps if deterioration

– Viral – peribronchial wall thickening, hyperinflationhyperinflation

– Bacterial ‐ lobar, segmental infiltrates, effusion – Atypical – interstitial infiltratesAtypical  interstitial infiltrates

Characteristics of Streptococcus pneumoniae and atypical bacterial infections in children 2-5 years of age with community-acquired pneumoniapneumonia.Esposito S et al Clin Infect Dis. 2002;35(11):1345-52

• S. pneumoniae infections were diagnosed inS. pneumoniae infections were diagnosed in 48 patients (24.5%)

At i l b t i l i f ti i 46 (23 5%)• Atypical bacterial infections in 46 (23.5%)

• Mixed infections in 16 (8.2%)( )

Comparison of radiographic findings for 196 children who were evaluated in a study of pediatric community-acquired y p y qpneumonia:

Findings Streptococcuspneumoniae

Atypical bacteria(46)p

(48)( )

Hyperinflation 5 (10.4) 6 (13)

Peribronchial wall hi k i

3 (6.3)  4 (8.7)thickening

Perihilar linearopacities

15 (31.3) 20 (43.5))

Reticulonodular 13 (27.1) 21 (45.7)infiltrate

Segmental or lobarconsolidation

18 (37.5) 12 (26.1)

Bilateral 7(14.6) 4(8.7)Bilateral consolidations

7(14.6) 4(8.7)

Pleural effusion 3 (6.3)  3 (6.5)

Chest RadiographsChest Radiographs• Should they be done?Should they be done?

• How many views?

• Whose interpretation?

Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in childrenchildren.Swingler G et al Lancet 1998 7;351:404-8

• Objective - to assess the impact of chestObjective to assess the impact of chest radiography on clinical outcome

M th d 522 hild d 2 t 59• Methods - 522 children aged 2 to 59 morandomly allocated to have CXR or not

• main outcome was time to recovery

Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in childrenchildrenSwingler G et al Lancet 1998 7;351:404-8

• Results:Results:

– median time to recovery was 7 days in both groups

– antibiotic use was higher in the CXR group(60.8% vs 52.2%, p=0.05)

• Routine use of chest radiography was not beneficial

Radiographic interpretation in the emergency departmentBrunswick J The American Journal of Emergency Medicine 1996;14: 346 348Brunswick J The American Journal of Emergency Medicine 1996;14: 346-348

• 99.0% of all emergency department99.0% of all emergency department radiographs were read correctly on initial review by ED attending physicians.

• Of all misread radiographs, less than half (46%) were deemed clinically significant and(46%) were deemed clinically significant and required a follow-up intervention

Pediatric Emergency Physician Interpretation of Plain Radiographs: Is routine Review by a Radiologist Necessary and C t Eff ti ?Cost Effective?Simon HK et al Annals of Emergency Medicine 1996 27(3):295-298

• Objective - to determine the concordance rateObjective to determine the concordance rate of plain radiograph interpretations by PEP and pediatric radiologists

• Methods - a prospective series of patients undergoing radiography had PEPundergoing radiography had PEP interpretation compared with radiology interpretation within 24 hp

Pediatric Emergency Physician Interpretation ...Simon HK et al. Annals of Emergency Medicine 1996 27(3):295-298

• Results - concordance rate of 90.2%Results concordance rate of 90.2% (638 of 707)

– 19 of 69 discordant interpretations required changes in management:

f l f»9 false‐negatives ‐ 5 fractures,                       2 pneumonia, 1 sinusitis, 1 cardiomegaly

»10 false positives 5 fractures»10 false‐positives ‐ 5 fractures, 4 pneumonia, 1 sinusitis

• no adverse outcomes resulted

The effect of Picture Archiving and Communications Systems on the accuracy of diagnostic interpretation of pediatric emergency physicians.y g p p g y p yGouin S et al Acad Emerg Med 2006;13(2):186-90

• To compare the accuracy of diagnosticTo compare the accuracy of diagnostic interpretation of radiographs by pediatric emergency physicians:

• before (2001) and after (2002) the introduction of PACS 

The effect of Picture Archiving and Communications Systems on the accuracy of diagnostic interpretation of pediatric emergency physicians.y g p p g y p yGouin S et al Acad Emerg Med. 2006;13(2):186-90

• Diagnostic performance for the two timeDiagnostic performance for the two time periods was as follows:

– Conventional = 98.1% – PACS = 98.5%

Should a lateral chest radiograph be routine in suspected pneumonia?in suspected pneumonia?Kennedy J et al. Aust Paediatr. J. 22:299-300, 1986 April.

• Objective - to determine if a lateral viewObjective to determine if a lateral view provides additional diagnostic information to the frontal

• Methods - retrospective review of 414 chest films of children aged 1 to 12films of children aged 1 to 12

– frontal film interpreted and then lateral film interpreted by a pediatric radiologist

Childhood Pneumonia ‐ A Pediatric Emergency Medicine Perspective

Should a lateral chest radiograph be routine in suspected pneumonia?in suspected pneumonia?Kennedy J et al. Aust Paediatr. J. 22:299-300, 1986 April.

• Results - 215 of 414 (52%) pneumoniaResults 215 of 414 (52%) pneumonia positive

– 206 frontal films positive– 9 (2.2%) lateral films additionally positive

• frontal film should be the initial film projectionfrontal film should be the initial film projection

Childhood Pneumonia ‐ A Pediatric Emergency Medicine Perspective

Occult InfectionsOccult Infections• BacteremiaBacteremia

• Before pneumococcal conjugate vaccines, ∼1% with l b t i h d b t i l i itipneumococcal bacteremia had bacterial meningitis. 

• PneumoniaPneumonia

• Occult pneumonia is defined as radiographic i i i h i f ipneumonia patients without signs of pneumonia.

Clinical predictors of occult pneumonia in the febrile child.child. Murphy C et al Acad Emerg Med 2007;14:243-9

• Clinical features associated with a higherClinical features associated with a higher likelihood of occult pneumonia included:

– presence of cough and duration > 10 days,– fever for >5 days,– fever >39°C, and– leukocytosis (WBC count >20 000/μL)

Right-lower-lobe pneumonia and acute appendicitis in childhood: A therapeutic disorderG R J l f P di t i S 1973 8 33 35Gongaware R, Journal of Pediatric Surgery 1973;8:33-35

• Two children with simultaneous right-lower-Two children with simultaneous right lowerlobe pneumonia and acute appendicitis had uneventful recoveries after early diagnosis and appendectomy.

• The presence of right-lower-lobe pneumonia• The presence of right-lower-lobe pneumonia does not exclude the possibility of simultaneous acute appendicitis.pp

Pathogen DetectionPathogen Detection• AspirationAspiration

• Sputum

• Serology

• Molecular Studies - PCR

Blood TestsBlood Tests• Complete blood countComplete blood count

• Blood culture

• Inflammatory Markers

GuidelinesGuidelines• Practice guidelines are:Practice guidelines are:

• “systematically developed statements to assist titi d ti t i ki d i i b tpractitioners and patients in making decisions about 

appropriate health care for specific clinical circumstances”

GuidelinesGuidelines• Guidelines for the management of community-Guidelines for the management of community

acquired pneumonia in adults:

• decrease morbidity and mortality rates

What has changed?What has changed?• PCVPCV

– Pneumococcal conjugate vaccines have reduced pneumonia admissions by 25 %

C S• Penicillin-resistant streptococcus, CA-MRSA

• InfluenzaInfluenza

The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of AmericaDiseases Society and the Infectious Diseases Society of America Bradley J et al.Clin Infect Dis August 30, 2011

• Evidence-based guidelines prepared by expert g p p y ppanel:

• community pediatrics• community pediatrics,• public health, and• the pediatric specialties of 

– critical care,– emergency medicine,– hospital medicine,p ,– infectious diseases, – pulmonology, and – surgery. g y

What Imaging Tests Should Be Used in a Child With S t d CAP i O t ti t S tti ?Suspected CAP in an Outpatient Setting?

• Routine chest radiographs are not necessary for the g p yconfirmation of suspected CAP in patients well enough to be treated in the outpatient setting

• Cannot reliably distinguish viral from bacterial CAP

When Does a Child or Infant With CAP Require Hospitalization?Hospitalization?

• Infants less than 3–6 months of age withInfants less than 3 6 months of age with suspected bacterial CAP

M d t t CAP• Moderate to severe CAP

• respiratory distress and hypoxemia (saturation of p y yp (oxygen <90 % at sea level)

When Does a Child or Infant With CAP Require Hospitalization?Hospitalization?

• Suspected or documented community-Suspected or documented communityassociated methicillin-resistant Staphylococcus aureus (CA-MRSA)

• Children and infants for whom

– there is concern about careful observation at home or

– who are unable to comply with therapy

TreatmentTreatment• Congruent with CPS GuidelinesCongruent with CPS Guidelines

New GuidelinesNew Guidelines

Canadian Paediatric Society

Pediatric Infectious Diseases Society andPediatric Infectious Diseases Society and Infectious Disease Society of America

Pneumonia in healthy Canadian children and youth:Practice points for managementCPS I f ti Di d I i ti C ittCPS Infectious Diseases and Immunization CommitteeLe Saux N and Robinson J Paediatr Child Health 2011;16(7):417-20

• Role of chest radiographsRole of chest radiographs

• Empirical therapy

• Severity• Pleural Effusion• Risk of co‐infection

Chest RadiographsChest Radiographs• “unless it is totally impractical, a chestunless it is totally impractical, a chest

radiograph should be performed to confirm the diagnosis of pneumonia”

• If the clinical picture and CXR are compatible with bacterial pneumonia then treatwith bacterial pneumonia then treat

CPS GuidelinesCPS Guidelines• Empirical antimicrobial therapy for previouslyEmpirical antimicrobial therapy for previously

healthy children 3 months to 17 years of age with community-acquired, radiologicallyproven pneumonia of suspected bacterial etiology

• Four step treatment guideline

Step 1Step 1

Assess severity and features of pneumonia?

TreatmentTreatment• A.) Most cases of nonsevere pneumoniaA.) Most cases of nonsevere pneumonia

• does not require hospital admission or• requires admission and minimal supplemental oxygen (fraction of inspired oxygen less than 0.30) and

• is in minimal respiratory distressis in minimal respiratory distress

• high‐dose amoxicillin or ampicillin for 7 to 10 daysg p y

TreatmentTreatment• B.) Nonsevere pneumonia with primaryB.) Nonsevere pneumonia with primary

features of atypical

• subacute onset, prominent cough, minimal leukocytosis, nonlobar infiltrate, school‐aged

– clarithromycin or azithromycin

TreatmentTreatment• C.) Severe pneumoniaC.) Severe pneumonia

• requires significant supplemental oxygen,• patient is in moderate respiratory distress, and• may require intensive care

• ceftriaxone or cefotaxime plus clarithromycin or azithromyciny

Step 2Step 2

Assess whether the child has proven or clinically suspected influenza plus evidence of

secondary bacterial infection?secondary bacterial infection?

TreatmentTreatment• Consider adding an antiviral for influenzaConsider adding an antiviral for influenza

• Nonsevere pneumonia –i illi / l l t f i iamoxicillin/clavulanate po or cefuroxime iv

• Severe pneumonia – ceftriaxone or pcefotaxime plus clarithromycin po or azithromycin po/iv +/- cloxacillin

Step 3Step 3

Assess whether the the child also has a pleural effusion?

TreatmentTreatment• Small – follow closely for clinical deteriorationSmall follow closely for clinical deterioration

and antibiotics in step 1 and 2

M d t t l id l l t• Moderate to large – consider pleural tap, ceftriaxone or cefotaxime, +/- clindamycin

Pediatric Complicated Pneumonia Position StatementHospital Paediatrics SectionChib k T t l P di t Child H lth 2011 16(7) 425 27Chibuk T, et al. Pediatr Child Health 2011;16(7):425-27

• EmpyemaEmpyema

• Abscess

• Necrotizing Lung

EmpyemaEmpyema• Intrapleural pusIntrapleural pus

• Exudative parapneumonic effusion (stage 1)

• Fibrinopurulent stage with loculations (stage 2))

• Organized with a thick fibrinous peel (stage 3)

EmpyemaEmpyema• Small parapneumonic effusions are commonSmall parapneumonic effusions are common

• Increasing incidence

• Etiology

• Streptococcus pneumonia, Staphylococcus aureus, Streptococcus pyogenes (Group A streptococcus)

• Methicillin resistant S aureus (MRSA)• Methicillin‐resistant S aureus (MRSA)• Emerging non‐vaccine serotypes of pneumococcus

Empyema: DiagnosisEmpyema: Diagnosis• UltrasoundUltrasound

• can estimate the size• can diffentiate free‐flowing from loculated

• CT

Empyema ManagementEmpyema Management• AntibioticsAntibiotics

• Cefotaxime or ceftriaxone– Clindamycin– vancomycin

• Procedural interventions

• If in moderate to severe respiratory distress

Empyema TreatmentEmpyema Treatment• Procedural InterventionsProcedural Interventions

– Thoracentesis– Chest tube placement with or without fibrinolytics– Video‐assisted thorascopic surgery (VATS)– Open thoracotomy with decortication

Step FourStep Four

Do features suggest pneumonia could be due to MRSA?

TreatmentTreatment• If MRSA – add vancomycin or linezolidIf MRSA add vancomycin or linezolid

• Severe and MRSA accounts for more than 5% of all S. A i th itAureus in the community

• Colonized with MRSA and severe pneumonia• Rapidly progressive diseaseRapidly progressive disease• Pneumatocele• Septic shock or purpura fulminansp p p

TreatmentTreatment• Randomized, clinical trials looking at clinicalRandomized, clinical trials looking at clinical

outcomes of high-dose vs. regular dose amoxicillin are lacking

Comparison of standard versus double dose of amoxicillin in the treatment of non-severe pneumonia in children aged 2–59 months: a multi-centre, double blind, randomised controlled trial in Pakistanrandomised controlled trial in PakistanHazir T et al Arch Dis Child 2007;92:291-297

• A double blind randomised controlled trialA double blind randomised controlled trial

• Children aged 2–59 months with non-severe i d i d t ipneumonia were randomised to receive:

– either standard (45 mg/kg/day) for 3 days oreither standard (45 mg/kg/day) for 3 days or– double dose (90 mg/kg/day) oral amoxicillin

• Final outcome was treatment failure by day 5.

Comparison of standard versus double dose of amoxicillin in the treatment of non-severe pneumonia in children aged 2–59 months: a multi-centre, double blind, randomised controlled trial in Pakistanrandomised controlled trial in PakistanHazir T et al Arch Dis Child 2007;92:291-297

• 876 children completed the study.876 children completed the study.

• 437 were randomised to standard and • 439 to double dose oral amoxicillin

• Therapy failure by day 5:• Therapy failure by day 5: 

• 20 (4.5%) children in the standard group• 25 (5.7%) in the double dose group 

Comparison of standard versus double dose of amoxicillin in the treatment of non-severe pneumonia in children aged 2–59 months: a multi centre double blind randomised controlled trial in Pakistanmulti-centre, double blind, randomised controlled trial in PakistanHazir T et al Arch Dis Child 2007;92:291-297

• Conclusion:Conclusion:

– Clinical outcome in children aged 2–59 months with non‐severe pneumonia is the same with standard and double dose oral amoxicillin.

Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pnemonia in children (Review)(Review)Mulholland S et al Cochrane Library 2010, Issue 7

• To determine whether antibiotics are effectiveTo determine whether antibiotics are effective in the treatment of LRTI secondary to M. pneumoniae infections

• Insufficient evidence to draw any specific conclusions about efficacyconclusions about efficacy

Take Home MessageTake Home Message• Respect pneumoniaRespect pneumonia

• Measure the respiratory rate accurately

• Order a chest radiograph

• Prescribe high dose amoxicillin

Future of PneumoniaFuture of Pneumonia• Viruses and Streptococcus pneumoniae mayViruses and Streptococcus pneumoniae may

synergistically contribute to clinical illness.

D ti l t i l d b t i l• Do sequential or concurrent viral and bacterial infections have a synergistic impact on disease evolution?disease evolution?

• Areas of the world without access to pneumococcal vaccine continue to see high rates of death caused by childhood pneumonia A recent analysis suggested thatpneumonia. A recent analysis suggested that pneumococcal vaccination in 72 developing countries could prevent 262,000 deaths per

ConclusionConclusion• Given the high probability that CAP is caused byGiven the high probability that CAP is caused by

at least 1 of these infections, therapy should cover all of the possibilities.

• Macrolides are not always active in vitro against S. pneumoniae, and resistance of up to 50% has p pbeen reported.

• The combination of a b-lactam plus a macrolide• The combination of a b lactam plus a macrolide could be suggested in the first-line treatment of CAP in immunocompetent children aged 2–5 years.

Take Home MessageTake Home Message• Treatment should be directed toward likelyTreatment should be directed toward likely

pathogens based on the patient’s age.

B i d i f ti• • Because mixed infections are common, positive viral testing may not preclude a bacterial causebacterial cause.

• • “Atypical” organisms such as Mycoplasma pneumoniae may occur in children younger than 5 years, despite historical dogma.

• Nothing has really changed!

• Table 4Table 4

• Dosing table for amoxicillin-clavulanate plus i illi t hi 90 /k /d f thamoxicillin to achieve 90 mg/kg/day of the

amoxicillin component and 6.4 mg/kg/day of the clavulanate component for acute otitisthe clavulanate component for acute otitis media that failed initial antimicrobial therapy*

• Drug Dose of amoxicillin from amoxicillinclavulanate

• Dose of amoxicillin to add

Cl li 125F i

CPS Admission Requirements• Unable to eat or drink - dehydrationUnable to eat or drink dehydration

• Oral therapy compliance, Social situation

• Hypotension, Sepsis

• Sats less than 92%

• Vomiting, tachypnea, retractionsVomiting, tachypnea, retractions

• Empyema, abscess Less than 6 months –diffi lt f i t i idifficult for caregivers to recognize pneumonia

What Diagnostic Laboratory and Imaging Tests Should Be Used in a Child With Suspected CAP in an pOutpatient Setting?

• Routine chest radiographs are not necessary for the g p yconfirmation of suspected CAP in patients well enough to be treated in the outpatient setting

• Chest radiographs, posteroanterior and lateral, should be obtained in patients with suspected or doc menteddocumented:

• hypoxemia or significant respiratory distress and• in those with failed initial antibiotic therapy to verify the presence or absence of complications of pneumonia, including parapneumonic effusions, necrotizing pneumonia, and pneumothorax.

•

Which Anti-Infective Therapy Should Be Provided to a Child With S t d CAP i I ti t S tti ?Child With Suspected CAP in Inpatient Setting?

• Ampicillin or penicillin G should be administered to the fully immunized infant or school-aged child admitted to a hospital ward with CAP when local epidemiologic data document lack of substantial high-level penicillin resistance for invasive S. pneumoniae.

• Empiric therapy with a third-generation parenteral cephalosporin (ceftriaxone or cefotaxime) should be prescribed for hospitalized infants and children:

• in regions where local epidemiology of invasive pneumococcal strains documents high‐level penicillin resistance, or

• for infants and children with life‐threatening infection, including those with empyema.• Non–β-lactam agents, such as vancomycin, have not been shown to be

more effective than third-generation cephalosporins in the treatment of pneumococcal pneumonia for the degree of resistance noted currently in North America (weak recommendation; moderate quality evidence)North America. (weak recommendation; moderate-quality evidence)

•

Which Anti-Infective Therapy Should Be Provided to a Child With S t d CAP i I ti t S tti ?Child With Suspected CAP in Inpatient Setting?

• Empiric combination therapy with a macrolide (oral or parenteral), in addition to a β-lactam antibiotic, should be prescribed for the hospitalized child for whom M. pneumoniae and C. pneumoniaeare significant considerations; diagnostic testing should be

f d if il bl i li i ll l t ti fperformed if available in a clinically relevant time frame.

• Vancomycin or clindamycin (based on local susceptibility data) should be provided in addition to β lactam therapy if clinicalshould be provided in addition to β-lactam therapy if clinical, laboratory, or imaging characteristics are consistent with infection caused by S. aureus

Which Anti-Infective Therapy Should Be Provided to a Child With Suspected CAP in Both Outpatient and p pInpatient Settings?

• Empiric combination therapy with a macrolide (oral or parenteral), in addition to a β-lactam antibiotic, should be prescribed for the hospitalized child for whom M. pneumoniae and C. pneumoniaeare significant considerations; diagnostic testing should be

f d if il bl i li i ll l t ti fperformed if available in a clinically relevant time frame

• Vancomycin or clindamycin (based on local susceptibility data) should be provided in addition to β lactam therapy if clinicalshould be provided in addition to β-lactam therapy if clinical, laboratory, or imaging characteristics are consistent with infection caused by S. aureus (Table 7)

Which Anti-Infective Therapy Should Be Provided to a Child With Suspected CAP in Outpatient Setting?p p g

• Amoxicillin should be used as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin.

Which Anti-Infective Therapy Should Be Provided to a Child With S t d CAP i O t ti t S tti ?Child With Suspected CAP in Outpatient Setting?

• Amoxicillin should be used as first-line therapy for pypreviously healthy appropriately immunized school-aged children and adolescents with mild to moderate CAP for S pneumoniaeCAP for S. pneumoniae.

• Atypical bacterial pathogens (eg, M. pneumoniae), and less common lo er respirator tract bacterialand less common lower respiratory tract bacterial pathogens should also be considered.

Which Anti-Infective Therapy Should Be Provided to a Child With S t d CAP i O t ti t S tti ?Child With Suspected CAP in Outpatient Setting?

• Macrolide antibiotics should be prescribed forMacrolide antibiotics should be prescribed for treatment of children (primarily school-aged children and adolescents) evaluated in an outpatient setting with findings compatible with CAP caused by atypical pathogens.

– Laboratory testing for M. pneumoniae should be performed if available in a clinically relevant timeperformed if available in a clinically relevant time frame. 

Which Anti-Infective Therapy Should Be Provided to a Child With Suspected CAP in Both Outpatient and p pInpatient Settings?

• Influenza antiviral therapy should beInfluenza antiviral therapy should be administered as soon as possible to children with moderate to severe CAP consistent with influenza virus infection during widespread local circulation of influenza viruses,

ti l l f th ith li i ll iparticularly for those with clinically worsening disease documented at the time of an outpatient visitoutpatient visit.