Diagnosis, Treatment & Prevention of Community Acquired Pneumonia in Pediatrics

➡️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

PREPARE (Practice guideline REgistration for transPAREncy), WHO Collaborating Center for Guideline Implementation and Knowledge Translation, EBM Center, University of Lanzhou, Lanzhou, China. Registration Number: ((submitted and in process)). Link: http://www.guidelines-registry.org/