community acquired pneumonia dr sanjay lalwani vice principal professor and head department...

Community Acquired Pneumonia

Dr Sanjay LalwaniVice PrincipalProfessor and HeadDepartment PediatricsBVUMC, Pune26/07/[email protected]

Clinical recommendations

• Site-of-Care • Diagnostic Testing• Anti-Infective Treatment• Adjunctive Surgical and Non–Anti-infective

Therapy for Pediatric CAP• Management in the Child Not Responding to

Treatment• Discharge Criteria• Prevention

Definition of CAP

CAP is the presence of signs and symptoms of pneumonia in a previously healthy child due to an infection acquired outside of the hospital.

Guideline scopeo Age 3 months – 18 yearso Exclusionary conditions

• Immune deficiency• Chronic lung disease (e.g., cystic fibrosis)• Mechanical ventilation

• Site-of-Care Management Decisions• Diagnostic Testing for Pediatric CAP• Anti-Infective Treatment• Adjunctive Surgical and Non–Anti-infective



Hospitalization Indications

• Children and infants who have moderate to severe CAP

• Infants ,3–6 months of age with suspected bacterial CAP

• Children and infants with a suspicion or documentation of CAP caused by MRSA

• Concern about careful observation at home or who are unable to comply with therapy or unable to be followed up should be hospitalized.

WHO-Pneumonia definition

• Pneumonia -cough or difficult breathing and age-adjusted tachypnea: (age 2–11 months, >50/min; 1–5 years, >40/min; >5 years, >20 breaths/min)

• Severe pneumonia - cough or difficulty breathing plus one of the following: lower chest indrawing, nasal flaring, or grunting

• Very severe pneumonia -cough or difficulty breathing plus one of the following: cyanosis, severe respiratory distress, inability to drink or vomiting everything, lethargy, unconsciousness/convulsions

Criteria for ICU admission

• Requiring ventilation

• child has sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion.

• Pulse oximetry measurement is <92% with inspired oxygen of>0.50

• Child has altered mental status

• Site-of-Care Management Decisions• Diagnostic Testing for Pediatric CAP• Anti-Infective Treatment• Adjunctive Surgical and Non–Anti-infective



Outline

Diagnostic Testingo Pulse oximetryo Chest x-rayo Blood cultureo Atypical bacteria testingo Viral testingo Complete blood counts

Anti-Infective Treatment

Diagnostic Testing—Pulse Oximetry

Outpatient and inpatient

Recommendation Recommended

CommentsIn all children with pneumonia

and suspected hypoxemia.

The presence of hypoxemia should guide decisions and further diagnostic testing.

Recommendation strength

Strong

Evidence Quality Moderate

Initial Chest X-Ray—Recommendation

•

Outpatient Inpatient

Recommendation

Not Recommended

Recommended Recommended

CommentsFor confirmation

of suspected CAP in patient well enough to be treated in outpatient

setting (after evaluation in

office, clinic, or ED).

Patients with hypoxemia, significant respiratory

distress, and failed antibiotic

therapy; to verify presence or absence of complications

All patients hospitalized with CAP;

to document presence, size, and character of infiltrates and identify

complications that may require

interventionsRecommendation strength Strong Strong Strong

Evidence Quality

High Moderate Moderate

Repeat Chest X-Ray—Recommendation

Outpatient and Inpatient

Recommendation Not Recommended

Comments Not routinely indicated in children who recover

uneventfully

Recommendation strength Strong


Repeat Chest X-Ray—Recommendation Outpatient and Inpatient

Recommendation

Recommended Recommended Recommended

Comments For inadequate clinical

improvement, progressive

symptoms, or clinical

deterioration within 48–72 hours after initiation of antibiotics

In children with complicated

pneumonia with worsening respiratory distress or

clinical instability

4–6 weeks after the diagnosis of CAP in limited circumstances (e.g., recurrent pneumonia in same lobe or

suspicion of an anatomic anomaly)

Recommendation strength Strong Strong Strong

Evidence Quality

Moderate low Moderate

Blood culture —Recommendation

•


Recommendation

Not Recommended

Recommended Recommended

Comments

Non-toxic, fully immunized

children treated as outpatients

Failure to demonstrate

clinical improvement, progressive

symptoms, or deterioration

after initiation of antibiotic therapy

Requiring hospitalization for moderate-

severe bacterial CAP

Recommendation strength

Strong Strong Strong

Evidence Quality

Moderate Moderate Low

Atypical bacteria testing

•

Mycoplasmapneumoniae

Chlamydophila pneumoniae

Recommendation Recommended

NOT recommended

CommentsIf signs/symptoms

consistent with but not classic for

Mycoplasma; can help guide antibiotic

selection.

Reliable and readily available diagnostic

tests do not currently exist.

Recommendation strength Weak Strong


High

Viral testing

InfluenzaOther Respiratory

VirusesRecommendation Recommended Recommended

Comments

Use sensitive and specific tests.

Positive influenza test may decrease the need for additional tests and antibiotic use, while

guiding the use of antiviral agents in both outpatient

and inpatient settings.

Can modify clinical decision making in

children with suspected

pneumonia; antibiotics are not

required in the absence of findings

that suggest bacterial

co-infection.Recommendation strength Strong Weak

Evidence Quality High

Low

Complete blood count recommendation

•


Recommendation NOT Recommended

NOT Recommended

CommentsHowever, may provide

useful information in those with more serious disease for clinical management in the context of clinical

exam and other laboratory and imaging studies.

However, may provide useful

information for those with severe

pneumonia; to be interpreted in the context of clinical exam and other laboratory and

imaging studies.Recommendation strength Weak Weak

Evidence Quality Low

Low

Antibiotic Choice—Outpatient Age of Child Infant/pre school age School age

Recommendation

No antibiotics

AmoxicillinAmoxicilli

nAzithromyci

nComments

Antibiotics NOT

routinely requiredbecause

viral pathogens are most

prevalent.

First-line therapy if previously

healthy and immunized.

Provides excellent

coverage for S.

pneumoniae.

First-line therapy if previously

healthy and

immunized.

Consider atypical bacterial

pathogens.

For treatment of

older children

with findings compatible with CAP

caused by atypical

pathogens.

Strength Strong Strong Strong Weak

Evidence Quality

High Moderate Moderate Moderate

Antibiotic Choice—Outpatient Alternatives

Allergy Amoxicillin Azithromycin

Alternatives• 2nd/3rd

generation Cephalosporin• Clindamycin• Levofloxacin

• Doxycycline (>7 years old)

• Levofloxacin or Moxifloxacin

Antibiotic Choice—Inpatient

First Line Second Line

Recommendation

Ampicillin / PCN G3rd Generation Cephalosporin

Comments

Immunized infant, preschool, or school-

age child.

Non-immunized, in regions with high levels

of PCN resistant pneumococcal strains, or

in children with life-threatening infection.

Non-beta lactam agents (e.g., vancomycin) are

not needed for the treatment of

pneumococcal pneumonia.

Strength Strong Weak

Evidence Quality

Moderate Weak

Antibiotic Choice—Inpatient Secondary Agents

Atypical Bacteria S. aureus

Recommendation MacrolideVancomycin or Clindamycin

Comments In addition to beta-

lactam therapy if atypical bacteria

are significant considerations. Instead of beta-

lactam if findings are characteristic of atypical infection.

In addition to beta-lactam therapy if

clinical, laboratory, or imaging

characteristics are consistent with

infection caused by S. aureus.

Recommendation Strength

Weak Strong

Evidence Quality Moderate Low

Take home message

Test Should I do it? Comment

Pulse oximetry Yes

CXR No Consider in some circumstances

Repeat CXR No Consider in some circumstances

Influenza testing

Yes During influenza season

Mycoplasma Yes Encouraged if considering macrolide

Sputum No

Blood culture No Yes, if deterioration or no improvement

CBC No

Outpatient Bottom Line

Outpatient bottom line Role Antibiotic Comment

First-Line Amoxicillin

Alternate 2nd/3rd generation cephalosporin; clindamycin; levofloxacin

Alternate Macrolide Add to include coverage for atypicals.

Alternate Macrolide Substitute to include coverage for atypicals if pneumococcal coverage is not desired.

Test Should I do it? Comment

Pulse oximetry

Yes

CXR Yes

Repeat CXR No Consider in some circumstances

Influenza testing

Yes During influenza season

Mycoplasma Yes Encouraged if considering macrolide

Sputum Yes If child can provide

Blood culture Yes

CBC No

Inpatient Bottom Line

Inpatient bottom line Role Antibiotic Comment

First-Line Ampicillin

Alternate Cefotaxime or Ceftriaxone

If unimmunized

Alternate Macrolide Add to include coverage for atypicals.

Alternate Macrolide Substitute to include coverage for atypicals if pneumococcal coverage is not desired.

Thank you

community acquired pneumonia dr sanjay lalwani vice principal professor and head department...

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