- Executive Summary

➡️Introduction

A new clinical guideline for Community-Acquired Pneumonia (CAP) in children has been adapted to fit the Egyptian healthcare system. This process of customizing existing evidence-based clinical practice guidelines for local contexts offers a practical alternative to creating new ones from scratch, potentially enhancing their usefulness while conserving resources. This guideline aims to detail the diagnosis, treatment, and prevention of CAP in children in Egypt, as well as the adaptation methods employed to create Egypt's first National Guideline for CAP in children using the Adapted ADAPTE method. The entire adaptation process, encompassing the setup, adaptation, and finalization phases, is thoroughly described. This involved a guideline adaptation group (GAG) and an external review group by experts in clinical content [1].

The GAG modified ten main categories of recommendations from three original Clinical Practice Guidelines (CPGs). These recommendations cover a range of aspects, including common symptoms, criteria for hospital and intensive care unit admission, lab tests and imaging for diagnosis, selection and duration of empiric antibiotic treatment for outpatients and hospitalized children with uncomplicated CAP, the use of influenza antiviral therapy, monitoring the response to treatment, managing cases that don't respond to initial treatment, criteria for safe patient discharge, and CAP prevention. Several tools were developed to enhance the implementation of these guidelines, including two clinical algorithms for managing uncomplicated and non-responsive CAP in children, a pathway for assessing CAP severity in primary care, medication tables, simplified Arabic patient information, a PowerPoint presentation for CAP management, and online resources [1].

The finalized adapted CPG provides pediatricians and healthcare workers in Egypt with practical, evidence-based instructions for managing community-acquired pneumonia in children. This initiative underscores the effectiveness of the Adapted ADAPTE method and emphasizes the significance of collaboration between clinical and methodological experts in adapting national guidelines [1].

➡️Scope

This guideline focuses on prevention and management of community acquired pneumonia.

Guideline development process and methods

After reviewing all the inclusion and exclusion criteria and quality appraisal results, the GDG/ GAG recommended using the following source original clinical practice guidelines (CPGs):

1- British Thoracic Society (BTS) Guideline, 2011,

2- Infectious Diseases Society of America (IDSA) Guideline, 2011.

3- WHO Guideline 2012-2014.

We conducted Adolopment for these guidelines: (Adoption, Adaptation, and Development)

         -  Adoption for most of the guideline recommendations.

         -  Development of Good Practice Statements

Recommendations and Good Practice Statements (GPS)

This version of the CPG includes recommendations and good practice statements on the Diagnosis, Management & Prevention of Community acquired pneumonia in Children

The guideline covers children up to 14 years of age

We can summarize the guidelines’ recommendations for community acquired pneumonia in the following:

➡️Diagnosis

Clinical manifestations

▪️ Children with CAP may present with fever, tachypnea, difficult breathing, cough, and wheeze, and/or chest pain. (Very low- quality evidence, Conditional recommendation)

Indications for hospitalization

▪️Moderate to severe CAP. (High- quality evidence, Strong recommendation).

▪️  Infants 3–6 months of age with suspected bacterial CAP. (Low-quality evidence, Strong recommendation).

▪️ 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).

▪️ Documentation of CAP caused by a pathogen with increased virulence. (Low-quality evidence, Strong recommendation).

Indications for PICU admission

▪️  Pulse oximetry measurement ≤92% with inspired oxygen of ≥0.50. (Low-quality evidence, Strong recommendation).

▪️Sustained tachycardia, inadequate blood pressure or need for pharmacologic support of blood pressure or perfusion. (Moderate  quality evidence, Strong recommendation)

▪️Altered mental status, whether due to hypercarbia or due to hypoxemia as a result of pneumonia. (Low-quality evidence, Strong recommendation).

▪️ Impending respiratory failure or need for assisted ventilation. (Moderate  quality evidence, Strong recommendation)

Investigations

Laboratory 

▪️ Sputum culture and Gram stain (in hospitalized children who can produce sputum). (Very low- quality evidence, Conditional recommendation).

▪️  Nasopharyngeal culture. (High- quality evidence, Strong recommendation).

▪️ Blood culture. (High- quality evidence, Strong recommendation).

▪️ Biochemical and immunological methods: (High- quality evidence, Strong recommendation).

-  Urine: Rapid detection of the capsular polysaccharide (CPS) antigen of S. pneumoniae.

-  PCR.

Plain chest X-ray

▪️ Routine chest radiographs are not necessary for the confirmation of CAP diagnosis in the outpatient setting. (High- quality evidence, Strong recommendation).

▪️ 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).

▪️  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.

▪️ There is no clinical or radiological  way of reliability that can distinguish between the etiological agents. (High- quality evidence, Strong recommendation).

➡️Treatment

Empiric antimicrobial agents in children with CAP in outpatient settings

▪️ 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).

▪️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).

▪️  Alternatives: cefaclor, erythromycin, azithromycin, and clarithromycin. (Moderate- quality evidence, Strong recommendation).

▪️  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, Strong recommendation).

Influenza antiviral agents in infants and children with CAP in outpatient settings

(Moderate- quality evidence, Strong recommendation).

▪️ 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.

▪️  Because early antiviral treatment has been shown to provide maximal benefit, treatment should not be delayed for confirmation of positive influenza test results.

▪️Negative influenza diagnostic tests, especially rapid antigen tests, do not conclusively exclude influenza disease.

▪️ Treatment after 48 hours of symptomatic infection may still provide clinical benefit to those with more severe disease.

Empiric antimicrobial therapy in children hospitalized with non-complicated CAP

▪️ Ampicillin (or Ampicillin-Sulbactam) should be administered to the fully immunized patients. (Moderate- quality evidence, Strong recommendation).

▪️ Third-generation parenteral cephalosporin’s for Infants and children who are not fully immunized or those with life threatening infections. (Moderate- quality evidence, Conditional recommendation).

▪️   A combination of a macrolide (oral or parenteral), and 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).

▪️  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).

▪️  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).

▪️ Treatment courses of 10 days in moderate and severe cases. Infections caused by certain pathogens, notably CA-MRSA, may require longer treatment than those caused by Strep. Pneumonia. (Moderate- quality evidence, Strong recommendation).

Para-pneumonic Effusion in children presenting with CAP

▪️  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. (Moderate- quality evidence, Strong recommendation).

▪️ The size of the effusion is an important factor that determines the management.

▪️ The child’s degree of respiratory compromise is an important factor that determines management of Para pneumonic effusions. (Moderate- quality evidence, Strong recommendation)

▪️laboratory testing for pleural fluid includes Gram stain and bacterial culture of pleural fluid, and 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. (High-quality evidence, Strong recommendation).

▪️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).

▪️ 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).

▪️ 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).

Safe discharge of hospitalized children with CAP

▪️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).

▪️ When they demonstrate consistent pulse oximetry measurements> 90% in room air for at least 12–24 hours. (Moderate- quality evidence, Strong recommendation).

▪️ If they demonstrate stable and/or baseline mental status. (Very low- quality evidence, Strong recommendation).

▪️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

Role of vaccination in prevention of CAP (High-quality evidence, Strong recommendation).

▪️ Children should be immunized with vaccines for bacterial pathogens, including Strep. Pneumonia, Haemophilus influenza type b, and Pertussis.

▪️  All infants ≥6 months of age and all children and adolescents should be immunized annually with vaccines for Influenza virus to prevent CAP.

▪️  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.

Role of zinc in preventing CAP in children

▪️  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)

➡️Guideline Registration

- Recommendations

- Abbreviations

- Acknowledgements

▪️ The GDG/ GAG acknowledge EPG for its help in completing this project.

▪️   We acknowledge the British Thoracic Society, WHO and IDSA guidelines (the source original guidelines) for their cooperation in providing the permission for adapting our guidelines.

▪️  Finally, we wish the best for all our patients and their families who inspired us. It is for them this work is being finalized.

Funding

- Glossary

➡️Acceptability: Is the extent to which the users are likely to adopt a recommendation It is based on internal qualities such as clarity, comprehensiveness, and logical reasoning and on external factors such as the burden imposed on the process and system of care, patient and providers attitudes and beliefs and patients’ needs expectations and preferences.

➡️Adaptation (of guidelines): It is the systematic approach to considering the use and/or modification of guidelines produced in one cultural and organizational setting for application in different context. Adaptation can be used as an alternative to de novo guidelines development or for customizing existing guidelines to suit the local context.

➡️Admission

Admission, for the purpose of this guideline, refers to a child being registered and entering inpatient care as a patient. This is distinguished from the term “enrolment”, which is used for outpatient care.

➡️Adoption (of guidelines): It is the acceptance of guidelines after the assessment of the quality, currency, and content. When health care providers (or other users of recommendations) use the adopted guidelines, they feel committed to change their practices in accordance with the recommendations of the guidelines. 

➡️Applicability: It is the extent to which the users can put a recommendation into practice, based on internal qualities such as a clearly defined eligible patient population that matches the population to which the intervention is targeted in the local setting and external factors such as the availability of the necessary knowledge, skills, provider time, staff, equipment, and other resources.

Applicability is sometimes taken as a synonym for feasibility:

•  Feasibility of the acquisition of necessary skills and knowledge.

•  Feasibility of the necessary increase in provider time, staff, equipment, and so on.

➡️Culture: Culture represents the norms and values of a specific group, community or population.

➡️Diffusion: It is a passive means of transferring knowledge; it is not directed towards a target audience (e.g. publication of articles in medical journals).

➡️Dissemination  : It is more active than diffusion in that it targets specific audients and involves tailoring the information for these audients (e.g. dissemination strategies including targeted mailings, presentations and press conferences.

➡️Evidence-based principles: Evidence-Based Medicine (EBM) has been defined as the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

➡️Evidence tables: They are summaries of the most salient information from studies identified in the systematic review. The elements of evidence tables are dependent on the types of information in studies related to a particular topic but might include information such as the article reference, the study type (e.g. RCT or Cohort), the number of patients and their characteristics and the intervention, comparison arms, outcome measures and effect sizes.

➡️Guidelines or Clinical Practice Guidelines (CPG): Systematically developed statements about specific health problems, intended to assist practitioners and patients in making decisions about appropriate health care.

➡️Guidelines consistency: Agreement between the evidence and the recommendations, based on:

• Comprehensiveness of the study search and selection process.

•  Coherence       between           the       results of         the       studies and            their interpretation by the guidelines authors.

•Transparency between interpretation and recommendations.

➡️Guidelines content: In the ADAPTE Manual and Resource Toolkit for Guidelines Adaptation document, guidelines content refers to the recommendations in the source guidelines.

➡️Guidelines currency: A CPG may be considered up to date when no new information on interventions, outcomes and performance justifies updating it.

➡️Guidelines quality: By quality of clinical practice guidelines, we mean the confidence that the potential biases of guidelines development addressed adequately and that the recommendations are both internally and externally valid and are feasible for practice. This process involves considering the benefits, harms and costs of the recommendations as well as the practical issues attached to them. Therefore, the assessment of quality includes judgments about the methods used for developing the guidelines, the content of the final recommendations, and the factors linked to their uptake.

➡️Guidelines topic: In the ADAPTE Manual and Resource Toolkit for Guidelines Adaptation document, the topic refers to the theme of the guidelines, as described in the guidelines title, for a targeted population (disease and patients) and intervention. The purpose, the audience, and the setting intended for the guidelines, although not necessarily explicitly stated in the title, are also part of the topic. A guideline on a given topic may contain more than one health question.

➡️Health question or clinical question or key question       

It is a precisely described health issue (e.g. clinical, professional practice or public health) relating to the topic of the guidelines? Guidelines may include one or more questions.

➡️Implementation: Implementation includes methods to promote the uptake of research findings into routine healthcare in both clinical and policy contexts and hence to improve the quality and effectiveness of healthcare. It includes the study of influences on healthcare professional and organizational behaviour.

➡️Intra-class correlations: Intra-class correlations provide a measurement of the extent to which two or more raters agree when rating the same set of things. It is a reliability index and is typically a ratio of the variance of interest over the sum of the variance of interest plus error.

➡️Recommendation: Recommendation is any statements that promote or advocate a particular course of action in clinical care.

➡️Stakeholder: A stakeholder is an individual, group and/or organization with a stake in your decision to implement a guideline. Stakeholders include individuals or groups who will be directly or indirectly affected by the implementation of a guidelines.

➡️Source guidelines: In the ADAPTE Manual and Resource Toolkit for Guidelines Adaptation document, source guidelines refer to those guidelines selected to undergo assessment of quality, currency, content, consistency, and acceptability/applicability and upon which an adapted guidelines may be based.

- Introduction

Community-acquired pneumonia (CAP) is a common pediatric infection [2]. It is defined as an acute infection of pulmonary parenchyma in a child caused by a pathogen acquired outside the hospital, that is, in the community [3]. The World Health Organization (WHO) estimates that approximately 2 million children under the age of 5 years die of pneumonia each year worldwide; the majority of these deaths occur in developing countries [4,5]. The mortality rate in developed countries is less than 1 per 1000 per year [6,7]. Africa experienced the highest disease burden with an estimated 0.27 pneumonia episodes per child-year [8]. In Egypt, it was estimated that 10% of childhood deaths below the age of 5 years is likely caused by pneumonia and other acute respiratory infections [9].

Nevertheless, community-acquired pneumonia is associated with enormous costs either directly through medical expenses or indirectly through loss of working hours by parents of sick children [10].

Although the specific etiologic agent is not identified in many cases of CAP in children, respiratory viruses such as RSV and Parainfluenza are detected in more than half of the cases [11]. Recently in 2019, COVID- 19 was discovered causing pandemic worldwide [12].

Pyogenic bacteria are detected in a relatively small proportion of CAP in children, but their early identification is critical, as they can cause severe.

and/or complicated pneumonia and even mortality [7]. Streptococcus pneumoniae is the most common bacterial cause of CAP. Mycoplasma pneumonia, Chlamydia pneumonia and Strep. pneumoniae are the predominant etiologies of CAP in school-aged children. Haemophilus influenza and group A Streptococci are fewer common causes [13].

The diagnosis is usually based on the clinical findings of fever, cough, respiratory distress (e.g. tachypnea, nasal flaring, intercostal, subcostal, and suprasternal retractions, and grunting), and/or radiologic evidence of an acute pulmonary infiltrate/consolidation [14, 15].

However, a reliable single test for identifying the specific pathogen (or pathogens) causing pneumonia does not exist, although an accurate and rapid etiologic diagnosis will result in improved care with focused antimicrobial therapy, fewer unnecessary tests and procedures and potentially shorter hospital stays in children with CAP [16].

The British Thoracic Society guidelines recommend that children with a clear clinical diagnosis of pneumonia should be treated with antibiotics, given that bacterial and viral pneumonia cannot be reliably distinguished from each other on clinical grounds [3].

Since the bulk of the global pneumonia disease burden occurs in countries with limited resources and weak health-care systems, a primary- care focused clinical case management approach was developed [17, 20]. The WHO acute respiratory infection case management strategy aimed to reduce child mortality by providing antibiotics to pneumonia cases and reducing inappropriate antibiotic use in children with upper respiratory tract infections [18].

➡️Purpose:

The intention of this CPG is to enhance appropriate utilization of community resources, decrease hospitalization and avoiding PICU admission, optimize medical management of patients with community acquired pneumonia (CAP), and provide optimal pharmacotherapy to prevent or minimize adverse effects of therapy.

This section describes what is intended with the guideline or what it is intended to achieve. For example, assisting or guiding Member States on determining a course of action, based on evidence, and leading to improvements in health indicators (e.g., mortality and disease prevalence), quality of life, or cost savings.

➡️Scope and target audience:

This CPG is intended to assist the practitioners, namely, pediatricians, primary health care (PHC) physicians, family practitioners, nurses, and clinical pharmacists to apply the best available evidence based researches to clinical decisions about the management of CAP in previously apparently healthy children older than 28 days up to 12 years.

This CPG is not intended to serve as a standard of medical care. Standards of care should be based on all the clinical data available for an individual case and are subjected to changes as scientific knowledge and technology advance in patterns of care evolve. The CPG recommendations will neither ensure a successful outcome in every case nor include all the proper methods of care. Also, they do not exclude other acceptable methods of care aimed at the same results.

The ultimate judgment must be made by the appropriate physician who is responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgment should only be made following discussion of the options with the patient, in light of the diagnostic and treatment choices available. However, it is advised that significant departures from the national CPGs or any local CPGs derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken.

• The target audience or intended end-users of this CPG include physicians (pediatrics, pediatric pulmonology, infectious diseases, primary health care, family medicine), nurses, and clinical pharmacists who care for children with CAP in Egypt.

- Methods

➡️Methods of search:

A comprehensive search for guidelines was undertaken to identify the most relevant guidelines to consider for adaptation. Keywords used for search are: Adolescent, Anti-Bacterial Agents / therapeutic use, Child, Child, Preschool, Community-Acquired Infections / diagnosis, Community-Acquired Infections / drug therapy, Community-Acquired Infections / microbiology, Community-Acquired Infections / prevention & control, Humans, Infant, Infant, Newborn, Pneumococcal Vaccines, Pneumonia / diagnosis, Pneumonia / drug therapy, Pneumonia / microbiology, Pneumonia / prevention & control, Practice Guidelines as Topic, and Vaccines, Conjugate, Child, Child, Preschool, Community-Acquired Infections / drug therapy, Humans, Pneumonia / therapy, Editorial Policies, Evidence-Based Medicine, Practice Guidelines as Topic / standards, and Reproducibility of Results.

Inclusion / exclusion criteria followed in the search and retrieval of guidelines to be adapted:

• Selecting only evidence-based guidelines (guideline must include a report on methodology of development including the systematic literature searches and explicit links between individual recommendations and their supporting evidence)

• Selecting national and/or international guidelines

• Specific range of dates for publication (using Guidelines published or updated 2013 and later or the last 5 years)

• Selecting peer-reviewed publications only

• Selecting guidelines written in English language

• Excluding guidelines written by a single author

The following three categories of databases and websites were searched:

1. CPG databases and libraries (e.g., GIN, ECRI, SIGN, DynaMed, BIGG-REC PAHO)

2.  Bibliographic databases (e.g., PubMed, Google Scholar)

3. Specialized professional societies (related to the pediatric subspecialty)

All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least two members. The panel decided a cut-off point or rank the guidelines (any guideline scoring above 60% on the rigor dimension was retained)

After reviewing all the previous criteria the GDG/ GAG recommended using 3 guidelines:

1-   British Thoracic Society (BTS) Guideline, 2011,

2-  Infectious Diseases Society of America (IDSA) Guideline, 2011,

3-  WHO Guideline 2012-2014.

We did Adolopment for these guidelines: (Adoption, Adaptation, and Development)

         -  Adoption for most of the guideline recommendations.

         -  Development of Good Practice Statement

Contributors to the guideline development process:

Guideline Development Group (GDG)/ Guideline Adaptation Group (GAG):

The GDG/ GAG included two subgroups; the clinicians/ healthcare providers subgroup and the guideline methodologists’ subgroup.

➡️Clinicians Subgroups

The clinicians’ subgroup or clinical panel for this guideline included experts with a range of knowledge, technical skills and diverse perspectives in the field of pulmonology.

The main functions of the clinical panel were adolopment of community acquired pneumonia Guidelines, determining the scope of the guideline and guideline, reviewing the evidence, and formulating evidence-informed recommendations in case of changing strength of recommendations.

➡️Guideline Methodologists Subgroup

There were 7 guideline methodologists with expertise in guidelines development, adaptation, GRADE and translation of evidence into recommendations. Methodologists provided orientation and overview of evidence-informed guideline development processes using the GRADE approach, guideline adaptation using the Adapted ADAPTE, provided AGREE II assessment of the source guidelines in collaboration with the clinicians subgroup, generation of the EtD frameworks whenever applicable.

➡️External Review Group:

The External Review Group for this guideline comprises 4 clinical national experts who have interest and expertise in as well as eminent international reviewers……………………….

They were identified by Egyptian Pediatric Clinical Practice Guidelines Committee (EPG) as people who can provide valuable insights during the guideline development process.

The External Review Group was asked to comment on (peer review) the final guideline to identify any criticism on the content and to comment on clarity and applicability as well as issues relating to implementation, dissemination, ethics, regulations, or monitoring, but not to change the recommendations formulated by the GDG/ GAG. The members of the External Review Group were required to submit declarations of interest before the peer review process.

➡️Guideline Development/ Adaptation Group meetings:

GDG/ GAG meetings were organized virtually (weekly/bimonthly). Due to the extensive scope of

the guideline, EPG was responsible for overseeing the adolopment process. the timetable and objectives of each meeting. GDG/ GAG meetings were also attended by members of the methodologists. Working rules for each contributor type were outlined by the chair at the start of each meeting, covering aspects such as vocal rights, voting, and evidence to decision and recommendation formulating processes.

➡️Declarations of interests:

Prospective members of the GDG/ GAG were asked to fill in and sign the standard WHO declaration of interest and confidentiality undertaking forms. All guideline members and methodologists were also asked to fill in and sign the standard WHO declaration-of-interests.

Members of the external review group will be asked to fill in and sign the standard WHO declaration-of-interests form before the peer review process.

➡️Evidence for the guideline:

We used the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) for assigning the quality of evidence and strength of recommendations that includes the following definitions [13]. Informed by the evidence required for the GRADE Evidence to Decision (EtD) framework(s) was(were) done while considering changing strength of recommendations according to availability of some resources in the recommendations (both ETD and changing strength of recommendation were not done in this guideline).

Description of the interpretation of the GRADE four levels of certainty of evidence:

Table 1. Classification of the Quality of Evidence

GRADE EtD’s contextual factors, criteria and considerations that link to the strength of recommendations:

Criteria and Considerations:

1.  Benefits and harms: When a new recommendation is developed, desirable effects (benefits) need to be weighed against undesirable effects (risks/harms), considering any previous recommendation or another alternative. The larger the gap or gradient in favor of the desirable effects over the undesirable effects, the more likely that a strong recommendation will be made.

2. Certainty of the evidence about the effects: The higher the certainty of the scientific evidence base, the more likely that a strong will be made.

3. Values and preferences: If there is no important uncertainty or variability in how much people value the main outcomes, it is likely that a strong recommendation will be made. Uncertainty or variability around these values that could likely lead to different decisions, is more likely to lead to a conditional recommendation.

4. Economic implications: Lower costs (monetary, infrastructure, equipment or human resources) or greater cost-effectiveness are more likely to support a strong recommendation.

5. Equity and human rights: If an intervention will reduce inequities, improve equity or contribute to the realization of human rights, the greater the likelihood of a strong recommendation.

6. Feasibility: The greater the feasibility of an intervention to all stakeholders, the greater the likelihood of a strong recommendation.

7. Acceptability: If a recommendation is widely supported by health workers and program managers and there is widespread acceptance for implementation within the health service, the likelihood of a strong recommendation is greater.

 Table 2. Classification of the Strengths of Recommendations

Developing good practice statements:

The GDG/ GAG also developed good practice statements for this guideline, which are actionable messages relevant to the guideline questions. The justification for each good practice statement was carefully considered by the GDG/ GAG with an emphasis that they are clearly needed. Good practice statements were developed, guided by the following GRADE criteria:

1- Message is really necessary with regard to actual healthcare practice

2- Have large net positive consequence (relevant outcomes and downstream consequences) (GRADE EtD domains)

3- Collecting and summarizing the evidence is a poor use of time and resources

4- Include awell-documented, clear rationale connecting indirect evidence

5- Are clear and actionable statements.

The GDG/ GAG collectively drafted and finalized good practice statements with relevant justifications and remarks to help with their interpretation, with close support and input from the consultant and guideline methodologists.

We have used the Reporting Items for Practice Guidelines in Healthcare (RIGHT) extension for adapted guidelines (RIGHT-Ad@pt Tool) as a reporting checklist for this guideline adaptation process as recommended by the EQUATOR network.

- Evidence to recommendations: Considerations

The GDG/ GAG was guided by the results of the AGREE II appraisals of the eligible CPGs and thoroughly reviewed the recommendations of the original source WHO CPGs in consideration of local contextual factors related to the national Egyptian health system like burden of the disease, equity, acceptability, feasibility, and other relevant factors. The GDG decided through an informal consensus process to adopt most recommendation. Also, GDG/ GAG develops group of good practice statements to improve acceptability and feasibility.

- Implementation Tools and Considerations

To improve healthcare provision, quality, safety, and patient outcome, evidence-based recommendations must not only be developed, but also disseminated and implemented at national and local levels and integrated into clinical practice.

Dissemination involves educating related healthcare providers to improve their awareness, knowledge and understanding of the guideline’s recommendations. It is one part of implementation, which involved translation of evidence-based guidelines into real life practice with improvement of health outcomes for the patients.

Implementation requires an evidence-based strategy involving professional groups and stakeholders and should consider the local cultural and socioeconomic conditions. Cost-effectiveness of implementation programs should be assessed.

Specific steps need to be followed before clinical practice recommendations can be integrated into local clinical practice, particularly in low resource settings.

Steps of implementing community acquired pneumonia diagnosis, treatment, and prevention strategies into the Egyptian health system:

1.  Develop a multidisciplinary working group.

2. Assess the status of nutritional care delivery, care gaps and current needs.

3. Select the material to be implemented, agree on the main goals, identify the key recommendations for diagnosis, treatment and prevention and adapt them to the local context or environment.

4. Identify barriers to, and facilitators of implementation.

5. Select an implementation framework and its component strategies.

6. Develop a step-by-step implementation plan:

▪️ Select the target populations and evaluate the outcome.

▪️   Identify the local resources to support the implementation.

▪️   Set timelines.

▪️  Distribute the tasks to the members.

▪️   Evaluate the outcomes.

7.  Continuously review the progress and results to determine if the strategy requires modification.

Guideline implementation strategies will focus on the following: -

1.     For Practitioners

▪️ Educational meetings: conferences, lectures, workshops, grand rounds, seminars, and symposia.

▪️ Educational materials: printed or electronic information (software).

▪️  Web-based education: computer-based educational activities.

▪️  A trained person meets with providers in their practice setting to provide information with the intention of changing the provider’s practice. The information may include feedback on the performance of the provider(s).

▪️ Reminders: the provision of information verbally, on papers or on a computer screen to prompt a health professional to recall information or to perform or avoid a particular action related to patient care.

▪️ Optimize professional-patient interactions, through mass media campaigns, reminders, and education materials.

▪️ Practice tools: tools designed to facilitate behavioral/practice changes, e.g., flow charts.

2.     For Patients and care givers

▪️ Patient education materials (Arabic booklet): Printed/electronic information aimed at the patient/consumer, family, caregivers, etc.

▪️ Reminders: the provision of information verbally, on papers or electronically to remind a patient/consumer to perform a particular health-related behaviors.

▪️  Mass media campaigns.

3.     For Nurses

▪️ Educational meetings: lectures, workshops or traineeships, seminars, and symposia.

▪️ Educational materials: printed.

▪️ A trained person meets with nurses in their practice setting to provide information with the intention of changing the provider’s practice.

▪️Reminders: the provision of information verbally, on paper or on a computer screen to prompt them to recall information or to perform or avoid a particular action related to patient care.

▪️ Practice tools: tools designed to facilitate behavioral/practice changes.

4.     For Stakeholders

Plans have been made to contact with all the health sectors in Egypt including all sectors of the Ministry of Health and Population, National Nutrition Institute, University Hospitals, Ministry of Interior, Ministry of Defense, Non-Governmental Organizations, Private sector, and all Health Care Facilities.

▪️ Information and communication technology: Electronic decision support, order sets, care maps, electronic health records, office-based personal digital assistants, etc.

▪️ Any summary of clinical provision of health care over a specified period may include recommendations for clinical action. The information is obtained from medical records, databases, or observations by patients. Summary may be targeted at the individual practitioner or the organization.

▪️ Administrative policies and procedures.

▪️ Formularies: Drug safety programs, electronic medication administration records.

5. Other activities to assist the implementation of the adapted guideline’s recommendations include:

▪️ International initiative: Dissemination of the presented adapted CPG internationally via sending the final adapted CPG to the Guidelines International Network (GIN) Adaptation Working Group and contacting the CPG developers.

▪️  Gantt chart has been designed to manage the dissemination and implementation stages for the adapted CPG over an accurate time frame (Appendix).

➡️Guideline Implementation Tools

Educational materials based on this Adapted CPG for treatment of CAP in children have been made available in several forms including:

1.  Pathway for assessment of severity of CAP in Primary Care Facilities.

2.  Algorithm for treatment of CAP in Acute Care Facilities (Emergency Rooms).

3.  Power Point Presentation Lectures for diagnosis, treatment & prevention of CAP

Figure 1. Management of CAP in children

Figure 2. Management of non-responding pneumonia

Table 7. Parenteral Anti-infective Doses [31]

NB: For the child allergic to amoxicillin (choice is depending on the antimicrobial susceptibility of the pathogen). Use alternatives as clindamycin, trimethoprim- sulfamethoxazole or macrolides.

- Limitations and suggestions for further research needs

Future research recommendations for the management of community acquired pneumonia in children in the Egyptian context could include:

▪️ Assessment of Antibiotic Resistance Patterns: Research focusing on the evolving patterns of antibiotic resistance in CAP pathogens in Egypt. This can help in updating and optimizing antibiotic therapy guidelines specific to the region.

▪️  Evaluating the Impact of Air Quality on CAP Incidence: Investigating the correlation between air pollution levels in different regions of Egypt and the incidence or severity of CAP in children.

▪️Cultural and Socioeconomic Factors in Treatment Adherence: Studying how cultural beliefs, socioeconomic status, and health literacy among parents and caregivers in Egypt affect adherence to CAP treatment guidelines. This research could lead to more effective, culturally tailored health education and intervention strategies.

These recommendations aim to address specific challenges and characteristics of the Egyptian context, potentially leading to more effective prevention and management strategies for CAP in children.

Strengthen the evidence base of the next update of this guideline by generating GRADE summary of finding tables, evidence profiles, and EtD frameworks.

- Monitoring and evaluating the impact of the guideline.

The following are three performance measures or indicators for implementing this adapted CPG for community acquired pneumonia in children:

1.  Adherence to Antibiotics Guidelines

▪️Numerator: Number of children with community acquired pneumonia who received treatment as per guideline recommendations.

▪️  Denominator: Total number of children diagnosed with community-acquired pneumonia.

▪️ Data Source: Hospital or clinic patient records.

2.  Duration of Hospital Stay

▪️   Numerator: Total number of hospital stay days for children with CAP.

▪️   Denominator: Total number of children admitted with CAP.

▪️   Data Source: Hospital admission and discharge records.

3.  Rate of Readmission

▪️Numerator: Number of children readmitted with symptoms of CAP within a certain period (e.g., 30 days) after discharge.

▪️  Denominator: Total number of children initially admitted with CAP.

▪️   Data Source: Hospital readmission records. 

These key performance indicators are designed to measure the effectiveness and adherence to the guidelines, the efficiency of the treatment in terms of resource utilization (hospital stay), and the success of the treatment in preventing further complications (readmissions).

- Updating of the guideline

The EPG CAP GAG has decided to conduct the next review of this adapted CPG for updates after five years. This should be carried out in 2029 after checking for updates in the source CPGs, consultation of expert opinion on the changes needed for updating according to the newest evidence and recommendations published in this area and the clinical audit and feedback from implementation efforts in the aforementioned local healthcare settings except if any breakthrough evidence- based recommendations are published before that date. The process will be guided by the Checklist for the Reporting of Updated Guidelines (CheckUp) Tool that is freely provided by the AGREE Enterprise and by the Reporting Items for Practice Guidelines in Healthcare (RIGHT) extension for adapted guidelines RIGHT-Ad@pt Checklist.

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- Annexes

Annex Table 1.

Declaration of Conflict of Interests

The members of the guideline development/ adaptation group and the external review group have no academic, financial, or competing interests to declare and none of them were involved in the development of the original source guideline(s).

Any identified potential COI has been reported below.

Annex Table 3. Results of the AGREE II assessment of the three source guidelines for CAP.

Annex Table 4. Annex Nurses and Parents Educational Guide in Arabic

Guideline Registration: PREPARE-2023CN225.