Diagnosis, Treatment & Prevention of Community Acquired Pneumonia in Pediatrics

- Recommendations

N	Health questions	Source Guideline	Recommendations (Quality of evidence, Strength of Recommendation)
*Diagnosis*
Q1	In infants and children with CAP, what are the common clinical manifestations?	BTS 2011	Children with CAP may present with fever, tachypnea, difficult breathing, cough, and wheeze, and/or chest pain (Very low- quality evidence, Conditional recommendation)
Q2	In infants and children with CAP, what are the indications for hospitalization?	IDSA 2011	1. Moderate to severe CAP (High- quality evidence, Strong recommendation).
			2. Infants 3–6 months of age with suspected bacterial CAP (Low-quality evidence, Strong recommendation).
			3. If there is concern about careful observation at home or who are unable to comply with therapy or unable to be followed up (Low-quality evidence, Strong recommendation).
			4. Documentation of CAP caused by a pathogen with increased virulence (Low-quality evidence, Strong recommendation).
Q3	In infants and children with CAP, what are the indications for PICU admission?	IDSA 2011	1. Pulse oximetry measurement ≤92% with inspired oxygen of ≥0.50 (Low-quality evidence, Strong recommendation).
			2. Sustained tachycardia, inadequate blood pressure or need for pharmacologic support of blood pressure or perfusion (Moderate quality evidence, Strong recommendation) 3.
			4. Altered mental status, whether due to hypercarbia or due to hypoxemia as a result of pneumonia (Low-quality evidence, Strong recommendation) 5.
			6. Impending respiratory failure or need for assisted ventilation (Moderate-quality evidence, Strong recommendation)
Q4	In infants and children with CAP, what are the indications for micro- biological investigations?	BTS 2011	Microbiological investigations should not be considered routinely in those with milder disease or those treated in outpatient settings. Microbiological diagnosis should be attempted in children with severe pneumonia requiring pediatric intensive care admission, or those with complications of CAP (Very low- quality evidence, Conditional recommendation).
Q5	In infants and children presenting with CAP, which investigations are helpful in identifying a bacterial cause?	IDSA 2011	1. Sputum culture and Gram stain ing for hospitalized children who can produce sputum (Low-quality evidence, Conditional recommendation).
Q5		BTS 2011	2. Nasopharyngeal culture 3. Blood culture. 4. Biochemical and immunological methods: a. Urine: Rapid detection of the capsular polysaccharide (CPS) antigen of S pneumoniae. b. PCR. (High- quality evidence, Strong recommendation).
Q6	In infants and children presenting with CAP, 6a. What are the indications for blood culture?	IDSA 2011	1. Blood cultures should not be routinely performed in nontoxic, fully immunized (including Streptococcal & H. influenza) children with CAP managed in the outpatient setting (Moderate- quality evidence, Strong recommendation).
			2. Blood cultures should be obtained in children requiring hospitalization for presumed bacterial CAP that is moderate to severe, particularly those with complicated pneumonia (Low quality evidence, Strong recommendation).
			3. Blood culture should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy (Moderate- quality evidence, Strong recommendation).
			4. Repeated blood cultures should be obtained in children with bacteremia caused by S. aureus, to document resolution of bacteremia regardless of the clinical status (Low-quality evidence, Strong recommendation).
	6b. Are testing for viral pathogens recommended for diagnosis?	IDSA 2011	Sensitive and specific tests for the rapid diagnosis of respiratory viruses should be used in the evaluation of children with CAP. A positive influenza test may decrease the need for additional diagnostic studies and antibiotic use, while guiding appropriate use of antiviral agents in both outpatient and inpatient settings (High-quality evidence, Strong recommendation).
	6c. which investigations are helpful for identifying atypical bacteria?	IDSA 2011	Children with signs and symptoms suspicious for Mycoplasma pneumonia should be tested to help guide antibiotic selection (Moderate- quality evidence, Conditional recommendation).
		BTS 2011	1. Diagnostic testing for Chlamydia pneumoniae is not recommended as a reliable and 2. readily available diagnostic test. (High-quality evidence, Strong recommendation).
		BTS 2011	3. Paired serology (rising titers in antibody complement fixation tests) remains the mainstay for diagnosing M pneumoniae and C pneumoniae infections (Moderate- quality evidence, Strong recommendation).
Q7	In infants and children presenting with CAP what are the indications for complete blood cell count (CBC)?	IDSA 2011	A complete blood cell count should be obtained for patients with severe pneumonia, to be interpreted in the context of the clinical examination and other laboratory and imaging studies (Low-quality evidence, Conditional recommendation).
Q8	In infants and children presenting with CAP, are the acute phase reactants helpful in distinguishing between viral and bacterial causes?	IDSA 2011	1. Acute phase reactants cannot be used alone to distinguish between viral and bacterial causes of CAP (High-quality evidence, Strong recommendation).
			2. Acute-phase reactants need not be routinely measured in fully immunized children with CAP who are managed as outpatients, although for a more serious disease, acute-phase reactants may provide useful information for clinical management (Low-quality evidence, Strong recommendation).
			3. In patients with more serious diseases, such as those requiring hospitalization or those with pneumonia-associated complications, acute-phase reactants may be used in conjunction with clinical findings to assess response to therapy (Low-quality evidence, Conditional recommendation).
Q9	In infants and children presenting with CAP, are testing of electrolytes necessary for admitted patients?	BTS 2011	Plasma sodium, potassium, urea and/or creatinine should be measured at baseline and at least daily when on intravenous fluids (Low-quality evidence, Conditional recommendation).
Q10	In infants and children presenting with CAP, 10a. Is routine plain chest radiography (postero-anterior and lateral) necessary to confirm the diagnosis in the outpatient setting?	IDSA 2011	Routine chest radiographs are not necessary for the confirmation of CAP diagnosis in the outpatient setting (High- quality evidence, Strong recommendation).
	10b. Should plain chest radiographs be obtained in all patients hospitalized for management?	IDSA 2011	Chest radiographs (postero-anterior and lateral) should be obtained in all hospitalized patients with hypoxemia or significant respiratory distress to document the presence, size and character of parenchymal infiltrates and identify complications of pneumonia (Moderate- quality evidence, Strong recommendation).
	10c. Are repeated chest radiographs routinely required?	IDSA 2011	Repeated chest radiographs are not routinely required in children who recover from CAP. Repeated chest radiographs should be obtained for children who fail to demonstrate clinical improvement and those who have clinical deterioration within 48-72 hours after initiation of therapy. Repeated chest radiographs 4–6 weeks after the diagnosis of CAP should be obtained in patients with recurrent pneumonia involving the same lobe and in patients with lobar collapse at initial chest radiography with suspicion of an anatomic anomaly, chest mass, or foreign body aspiration (Moderate- quality evidence, Strong recommendation).
	10d. Is lung ultrasound recommended for the diagnosis of pneumonia?	IDSA 2011	Lung ultrasound has significantly high sensitivity & specificity compared to chest x-ray for the diagnosis of pediatric CAP (GPS) [19].
	10e. Is CT chest indicated in children with CAP?	IDSA 2011	CT chest is only indicated if the plain chest radiograph is not conclusive to confirm the presence of pleural fluid (High-quality evidence, Strong recommendation).
Q11	In infants and children with CAP, can clinical or radiological features distinguish between viral, bacterial, and atypical pneumonia?	BTS 2011	There is no clinical or radiological way of reliability that can distinguish between the etiological agents (High- quality evidence, Strong recommendation).
*Treatment*
Q12	In infants and children with CAP managed in outpatient settings, 12a. which empiric anti- biotic therapy should be provided?	WHO 2012-2014	Antibiotics are not routinely recommended for children younger than 5 years with non- severe pneumonia (i.e. fast breathing with no chest indrawing or danger sign) with a wheeze but with no fever (temperature <38 c) as the cause is most likely to be viral (Low- quality evidence, Strong recommendation).
		IDSA 2011	Amoxicillin (or amoxicillin clavulanic acid) should be used as first-line therapy in infants, children, and adolescents previously healthy and appropriately immunized with mild to moderate CAP, suspected to be of bacterial origin (Moderate- quality evidence, Strong recommendation).
		BTS 2011	Alternatives: cefaclor, erythromycin, azithromycin, and clarithromycin (Moderate- quality evidence, Strong recommendation).
		IDSA 2011	Macrolide antibiotics should be prescribed for treatment of children (primarily school-aged children and adolescents) with findings compatible with CAP caused by atypical pathogens (Moderate- quality evidence, Conditional recommendation).
	12b. What is the role of influenza antiviral therapy?	IDSA 2011	1. Influenza 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, particularly for those with clinically worsening disease documented at the time of an outpatient visit. 2. Because early antiviral treatment has been shown to provide maximal benefit, treatment should not be delayed for confirmation of positive influenza test results. 3. Negative influenza diagnostic tests, especially rapid antigen tests, do not conclusively exclude influenza disease. 4. Treatment after 48 hours of symptomatic infection may still provide clinical benefit to those with more severe disease. (Moderate- quality evidence, Strong recommendation)
Q13	In infants and children hospitalized with non- complicated CAP, 13a. what empiric antimicrobial therapy should be started?	WHO 2012-2014	1. Ampicillin (or Ampicillin-Sulbactam) should be administered to the fully immunized patients (Moderate- quality evidence, Strong recommendation).
		IDSA 2011	2. Third-generation parenteral cephalosporin’s for: Infants and children who are not fully immunized. Infants and children with life threatening infections. (Moderate- quality evidence, Conditional recommendation)
			3. A combination of a macrolide (oral or parenteral), & a β-lactam antibiotic, for whom M. pneumoniae and C. pneumoniae are significant considerations. Levofloxacin for children who reached growth maturity or who cannot tolerate macrolides (Moderate-quality evidence, Conditional recommendation).
			4. Vancomycin or clindamycin should be provided in addition to β-lactam therapy if clinical, laboratory, or imaging characteristics are consistent with infection caused by CA-MRSA Alternative: levofloxacin; addition of vancomycin or clindamycin for suspected CA-MRSA (Low-quality evidence, Strong recommendation).
			5. Antiviral therapy: · Oseltamivir · Ribavirin Influenza antiviral therapy should be administered as soon as possible to children with moderate to severe CAP consistent with influenza virus infection (High-quality evidence, Strong recommendation).
	13b. What is the appropriate duration of empiric anti-infective therapy?	IDSA 2011	1. Treatment courses of 10 days in moderate and severe cases. 2. Infections caused by certain pathogens, notably CA-MRSA, may require longer treatment than those caused by Strep. Pneumonia (Moderate- quality evidence, Strong recommendation).
		WHO 2012-2014, and IDSA 2011	Duration of treatment at least 5 days for mild disease managed on an outpatient basis (Moderate- quality evidence, Strong recommendation).
	13c.When parenteral antibiotics can be shifted to oral therapy?	IDSA 2011	Transition to oral therapy can take place as early as 2-3 days after the start of parenteral therapy if: Improvement in fever, cough, tachypnea, and supplemental oxygen dependency and Increased activity and appetite; supported by reduction in peripheral leukocyte counts and/or CRP or other acute phase reactants and absence of bacteremia (Low-quality evidence, Strong recommendation).
Q14	In infants and children hospitalized with non- complicated CAP, what is the role of chest physiotherapy?	BTS 2011	Chest physiotherapy is not beneficial and should not be performed in children with pneumonia (High- quality evidence, Strong recommendation).
Q15	In infants and children presenting with CAP, what are the common complications of CAP?	BTS 2011	1. Parapneumonic effusion is thought to develop in 1% of patients with CAP but, in those admitted to hospital, effusion may be found in as many as 40% of cases (Moderate- quality evidence, Strong recommendation).
			2. A clinician should consider empyema when a child has a persistent fever beyond 7 days or a fever not settling after 48 hours of antibiotics (Moderate-quality evidence, Strong recommendation).
			3. Suspicion of abscess or necrosis is often raised on the chest X-ray and diagnosis can be confirmed by CT scanning (Low-quality evidence, Conditional recommendation).
Q16	In infants and children presenting with CAP, how should a para pneumonic Effusion be identified?	IDSA 2011	Chest radiography should be used to confirm the presence of pleural fluid. If the chest radiograph is not conclusive, then further imaging with chest ultrasound or computed tomography (CT) is recommended (High-quality evidence, Strong recommendation).
Q17	In infants and children with CAP and parapneumonic effusion, 17a. what factors are important in determining whether drainage of the parapneumonic effusion is required?	IDSA 2011	1. The size of the effusion is an important factor that determines the management. 2. The child’s degree of compromise is an important factor that determines management of Para pneumonic effusions. (Moderate- quality evidence, Strong recommendation)
	17b. what are the drainage options for parapneumonic Effusions?	IDSA 2011	1. Small, uncomplicated parapneumonic effusions should not routinely be drained and can be treated with antibiotic therapy alone. 2. Moderate* parapneumonic effusions associated with respiratory distress, large*** parapneumonic effusions, or documented purulent effusion should be drained. (Moderate- quality evidence, Strong recommendation).
	17c. what laboratory testing should be performed on pleural fluid?	IDSA 2011	1. Gram stain and bacterial culture of pleural fluid should be performed whenever a pleural fluid specimen is obtained (High-quality evidence, Strong recommendation).
			2. Antigen testing or nucleic acid amplification through PCR increase the detection of pathogens in pleural fluid and may be useful for management (Moderate- quality evidence, Strong recommendation).
			3. Analysis of pleural fluid parameters, such as pH and levels of glucose, protein, and lactate dehydrogenase, rarely change patient management and are not recommended (Very low -quality evidence, Conditional recommendation).
			4. Analysis of the pleural fluid for white blood cell count with cell differential analysis is recommended primarily to help differentiate bacterial from mycobacterial etiologies and from malignancy (Moderate- quality evidence, Conditional recommendation).
	17d. what antibiotic therapy, and duration, is indicated for the treatment of parapneumonic effusion/ empyema?	IDSA 2011	1. When the blood or pleural fluid bacterial culture identifies a pathogenic isolate; antibiotic susceptibility should be used to determine the antibiotic regimen (High-quality evidence, Strong recommendation).
			2. In case of negative culture- of Para pneumonic effusions, antibiotic selection should be based on the treatment recommendations for patients hospitalized with CAP (Moderate- quality evidence, Strong recommendation).
			3. The duration of antibiotic treatment depends on the adequacy of drainage and on the clinical response of each patient. In most children, antibiotic treatment for 2–4 weeks is adequate (Low-quality evidence, Strong recommendation).
	17e. when should a chest tube be removed either after primary drainage or VATS?	IDSA 2011	A chest tube can be removed in the absence of an intra-thoracic air leak and when pleural fluid drainage is <1 ml/kg/24 hours, usually calculated over the last 12 hours (Very low -quality evidence, Strong recommendation).
Q18	In infants and children presenting with CAP, how should the clinicians follow up the child for the expected response to therapy?	IDSA 2011	Children on adequate therapy should demonstrate clinical and laboratory improvement within 48–72 hrs. Further investigations should be performed if no improvement within 48–72 h's or the condition deteriorates after admission and initiation of antimicrobial therapy (Moderate- quality evidence, Strong recommendation).
Q19	In infants and children with CAP not responding to treatment, what further management should be performed?	BTS 2011	If a child remains feverish or unwell 48 hours after treatment has commenced, re-evaluation should be performed with consideration given to possible complications. Answers to the following questions should be sought: 1. Is the patient having appropriate drug treatment and an adequate dosage? 2. Is there a lung complication of pneumonia as collection of pleural fluid with the development of empyema or evidence of lung abscess? 3. Has the patient a complication as immuno-suppression or coexistent disease as cystic fibrosis? 4. Is there a penicillin-resistant Strep. Pneumonia? (Very low -quality evidence, Conditional recommendation).
Q20	In infants and children with CAP, when hospitalized children can be safely discharged?	IDSA 2011	1. When they have documented overall clinical improvement, including level of activity, appetite, and decreased fever for at least 12–24 hours (Very low- quality evidence, Strong recommendation).
			2. When they demonstrate consistent pulse oximetry measurements > 90% in room air for at least 12–24 hours (Moderate-quality evidence, Strong recommendation).
			3. If they demonstrate stable and/or baseline mental status (Very low-quality evidence, Strong recommendation).
			4. If they have documentation that they can tolerate their home anti- infective regimen, whether oral or intravenous, and home oxygen regimen, if applicable before hospital discharge (Low-quality evidence, Strong recommendation).
*Prevention*
Q21	In infants and children what is the role of vaccination in prevention of CAP?	IDSA 2011	1. Children should be immunized with vaccines for bacterial pathogens, including Strep. Pneumonia, Haemophilus influenza type b, and Pertussis (High-quality evidence, Strong recommendation).
			2. All infants ≥ 6 months of age and all children and adolescents should be immunized annually with vaccines for Influenza virus to prevent CAP (High-quality evidence, Strong recommendation).
			3. Parents and caretakers of infants <6 months of age, including pregnant adolescents, should be immunized with vaccines for Influenza virus and Pertussis to protect the infants from exposure (low-quality evidence, Strong recommendation).
			4. High-risk infants should be provided immune prophylaxis against respiratory syncytial virus (RSV) – specific monoclonal antibodies to decrease the risk of severe pneumonia and hospitalization caused by RSV (High-quality evidence, Strong recommendation).
Q22	In infants and children what is the role of zinc in preventing CAP		In addition to antibiotics, oral zinc (10 mg/day for < 12 mo., 20 mg/day for ≥ 12 months given for 7 days) may reduce mortality among children in developing countries with clinically defined severe pneumonia (GPS) [28].