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Prepared for your next patient.

Current Diagnosis &

Treatment of
Community-Acquired
Pneumonia in Children
Highlights of the PIDS/IDSA National
Guidelines
Samir S. Shah, MD, MSCE, FAAP
Professor, Department of Pediatrics
University of Cincinnati College of Medicine
Director, Division of Hospital Medicine

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Disclaimers
Statements and opinions expressed are those of the authors
and not necessarily those of the American Academy of
Pediatrics.
Mead Johnson sponsors programs such as this to give
healthcare professionals access to scientific and educational
information provided by experts. The presenter has complete
and independent control over the planning and content of the
presentation, and is not receiving any compensation from Mead
Johnson for this presentation. The presenters comments and
opinions are not necessarily those of Mead Johnson. In the event
that the presentation contains statements about uses of drugs
that are not within the drugs' approved indications,Mead
Johnson does not promote the use of any drug for indications
outside the FDA-approved product label.

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Disclaimers continued
I have no financial conflicts of interest to disclose.
I have not received any compensation for preparing and
presenting this webinar.
I served as Associate Chair of the Pediatric Infectious
Diseases Society/Infectious Diseases Society of America
Pneumonia Guidelines Committee, the topic of this
presentation.
Sources of current research support:
o National Institute of Allergy and Infectious Diseases
o Agency for Healthcare Research and Quality
o Childrens Hospitals Association
o Robert Wood Johnson Foundation

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Objectives
Discuss the rationale for creating pediatric
community-acquired pneumonia (CAP)
national guidelines.
Describe currently recommended
diagnostic and treatment strategies for
CAP in the United States.

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Why Do We Need Guidelines?

Role of guidelines
o Assist in healthcare decision-making
o Reduce variation in clinical practice
o Lead to better patient care and outcomes

Only as good as the evidence on which

they are based
Most useful for conditions with substantial
variation in clinical practice and outcomes

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Context for the US Guidelines

CAP is the most common serious childhood
infection in the US.
o 3 million outpatient visits each year
o >150,000 hospitalizations each year
o Up to 15% of children hospitalized with CAP have a
serious pneumonia-associated complication such as
empyema.

In the US, there is substantial variation across

hospitals and physicians in diagnosis,
treatment, and outcomes.
Kronman MP. Pediatrics. 2011; Shah SS. J Hosp Med. 2011; Lee GE. Pediatrics. 2010; Shah SS. Pediatr Pulmonol.
2010

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Diagnostic Testing for CAP at 43

US Hospitals

Brogan TV. Pediatr Infect Dis J. 2012

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Diagnostic Testing for CAP at 43

US Hospitals

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Diagnostic Testing for CAP at 43

US Hospitals

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Treatment for CAP at 43 US

Hospitals

Data from Ambroggio LV, et al. Pediatr Infect Dis J. 2012

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Available Free Online and In Print

Guidelines available at: www.idsociety.org
Bradley JS, Byington CL, Shah SS, and Alverson B, Carter ER,
Harrison C, Kaplan SL, Mace S, McCracken G, Moore M, St. Peter
S, Stockwell J, Swanson JT. The management of communityacquired 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 America.
Clin Infect Dis. 2011;53:e25e76
Bradley JS, Byington CL, Shah SS, and Alverson B, Carter ER,
Harrison C, Kaplan SL, Mace S, McCracken G, Moore M, St. Peter
S, Stockwell J, Swanson JT. Executive Summary: 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 America. Clin Infect Dis. 2011;53:617630

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Consensus Development Based on

92 recommendations
Evidence
Consensus development based on evidence

o GRADE working group (Grading of

Recommendations, Assessment, Development, and
Evaluation)
o Method of assigning strength of recommendation and
quality of evidence to each recommendation

Strength of Recommendation (Strong or Weak)

Quality of Evidence (High, Moderate, or Low)

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Evidence-Based Guidelines
Clinical Recommendations
o
o
o
o
o

Site of care
Diagnostic testing
Anti-infective treatment
Adjunctive treatment
Management of the child not responding to
treatment
o Discharge criteria
o Prevention

Future research

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Evidence-Based Guidelines
Clinical Recommendations
o
o
o
o
o

Site of care
Diagnostic testing
Anti-infective treatment
Adjunctive treatment
Management of the child not responding to
treatment
o Discharge criteria
o Prevention

Future research

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Outline
Diagnostic Testing
o
o
o
o
o
o

Pulse oximetry
Chest x-ray
Blood culture
Atypical bacteria testing
Viral testing
Complete blood counts

Anti-Infective Treatment

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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 scope
o Age 3 months 18 years
o Exclusionary conditions
Immune deficiency
Chronic lung disease (e.g., cystic fibrosis)
Mechanical ventilation

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Diagnostic TestingPulse

Oximetry
Outpatient and
Inpatient
Recommendation
Comments

Recommended
In all children with
pneumonia and suspected
hypoxemia.
The presence of hypoxemia
should guide decisions and
further diagnostic testing.

Recommendation
Strength
Evidence Quality

Strong
Moderate

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Initial Chest X-Ray

Outpatient
Recommendation

Inpatient

Recommendati
on

NOT
Recommended
Recommended

Comments

All patients
Patients with
For confirmation
hospitalized with
hypoxemia,
of suspected CAP
CAP;
significant
in patient well
to document
respiratory
enough to be
presence, size, and
distress, and
treated in
character of
failed antibiotic
outpatient setting
infiltrates and
therapy; to verify
(after evaluation
identify
presence or
in office, clinic, or
complications that
absence of
ED).
may require
complications.
interventions.

Strength
Evidence
Quality

Recommended

Strong

Strong

Strong

High

Moderate

Moderate

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Initial Chest X-RayRationale

Chest x-rays (CXRs) not routinely required for
outpatient CAP
CXRs:
o Do not reliably distinguish bacterial from viral CAP or
among the various bacterial pathogens
o Impractical in office setting
Often requires travel to a separate facility
Barriers to physicians obtaining timely results

o CXR in outpatient setting infrequently changes clinical

management

Guideline provides guidance on when to perform CXR

in outpatient setting
Swingler GH. Cochrane Database Syst Rev. 2008; Swingler GH. Lancet. 1998; Novack V. J Intern Med. 2006; Alario
AJ. J Pediatr. 1987; Grossman LK. Ann Emerg Med. 1988

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Repeat Chest X-Ray

Recommendation

Outpatient AND
Inpatient
Recommendation
Comments

Recommendation
Strength
Evidence Quality

NOT Recommended

Not routinely indicated in

children who recover
uneventfully
Strong
Moderate

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Repeat Chest X-Ray

Outpatient AND Inpatient

Recommendation
Recommendation Recommended Recommended
Recommended
Comments

Recommendation
Strength
Evidence Quality

For inadequate
clinical
improvement,
progressive
symptoms, or
clinical
deterioration
within 4872
hours after
initiation of
antibiotics

In children with
complicated
pneumonia with
worsening
respiratory
distress or
clinical instability

46 weeks after
the diagnosis of
CAP in limited
circumstances
(e.g., recurrent
pneumonia in
same lobe or
suspicion of an
anatomic
anomaly)

Strong

Strong

Strong

Moderate

Low

Moderate

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Repeat Chest X-RayRationale

Repeat CXRs commonly identify persistent
or residual abnormalities 36 weeks later.
o Abnormalities rarely alter management.
o Abnormalities do not predict treatment failure
or worse clinical outcome.

Repeat CXRs represent unnecessary

radiation exposure to infants and children.

Gibson NA. BMJ. 1993; Virkki R. Pediatr Pulmonol. 2005; Grossman LK. Pediatrics. 1979; Wacogne I. Arch Dis
Child. 2003; Heaton P. N Z Med J. 1998; Bruns AH. Clin Infect Dis. 2007

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Blood CulturesRecommendations

Recommendati
on

Outpatient
Inpatient
NOT
Recommende Recommend
Recommended
d
ed

Comments

Non-toxic, fully
Failure to
Requiring
immunized children demonstrate clinical hospitalization for
treated as outpatients
improvement,
moderate-severe
progressive
bacterial CAP
symptoms, or

deterioration after
initiation of
antibiotic therapy
Strength
Evidence
Quality

Strong
Moderate

Strong
Moderate

Strong
Low

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Blood CulturesRationale
Outpatient
o Infrequently identifies pathogens (<2%)
o False-positives more common than true
positives at some hospitals
o Rarely informs outpatient management

Bonadio WA. Pediatr Emerg Care. 1988; Hickey RW. Ann Emerg Med. 1996; Shah SS. Arch Pediatr Adolesc Med.
2003; Shah SS. Pediatr Infect Dis J. 2011

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Blood CulturesRationale
Outpatient

o Infrequently identifies pathogens (<2%)

o False-positives more common than true positives
at some hospitals
o Rarely informs outpatient management

Inpatient
o
o
o
o

Positive in ~3% of uncomplicated pneumonia

Positive in ~15% with empyema
Allows for culture-directed therapy when positive
Provides local epidemiologic data

Bonadio WA. Pediatr Emerg Care. 1988; Hickey RW. Ann Emerg Med. 1996; Shah SS. Arch Pediatr Adolesc Med.
2003; Shah SS. Pediatr Infect Dis J. 2011

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Atypical Bacteria
Chlamydophila
Mycoplasma
TestingRecommendation

pneumoniae

Recommendati
on
Comments

Strength
Evidence
Quality

Recommended

pneumoniae
NOT
recommended

If signs/symptoms
Reliable and readily
consistent with but available diagnostic
not classic for
tests do not
Mycoplasma; can
currently exist.
help guide antibiotic
selection.
Weak
Strong
Moderate

High

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Atypical Bacteria
TestingRationale
Evolving understanding of M. pneumoniae
epidemiology
o Increasingly identified in younger children

Rapid tests (IgM and PCR) available

o Variable test accuracy
o Treatment is not mandatory, especially with
low likelihood of infection (e.g., negative test),
as benefit of macrolide antibiotics uncertain
Heiskanen-Kosma T. Pediatr Infect Dis J. 1998; Michelow IC. Pediatrics. 2004; Korppi M. Respirology. 2004;
Thurman KA. Clin Infect Dis. 2009

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Viral TestingRecommendations

Influenza
Recommendati
on
Comments

Strength
Evidence
Quality

Recommended

Other Respiratory
Viruses
Recommended

Use sensitive and specific

tests.
Can modify clinical decision
Positive influenza test may
making in children with
decrease the need for
suspected pneumonia;
additional tests and
antibiotics are not required
antibiotic use, while
in the absence of findings
guiding the use of antiviral
that suggest bacterial
agents in both outpatient
co-infection.
and inpatient settings.

Strong

Weak

High

Low

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Diagnostic TestingViral
Pathogens
Antibacterial therapy is not necessary in
children, either outpatients or inpatients,
with a positive test for influenza virus in
the absence of clinical, laboratory, or
radiographic findings that suggest
bacterial co-infection.
Strong recommendation; High-quality
evidence

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Viral TestingRationale
Influenza testing
o Positive tests reduce antibiotic use and
ancillary testing (e.g., CXR, CBC) by >50%.
o Positive tests guide antiviral treatment
decisions.
Early treatment improves outcomes.

Bonner AB. Pediatrics. 2003; Esposito S. Arch Dis Child. 2003; Iyer SB. Acad Emerg Med. 2006; Benito-Fernandez
J. Pediatr Infect Dis J. 2006

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Viral TestingRecommendations

Influenza
Recommendati
on
Comments

Strength
Evidence
Quality

Recommended

Other Respiratory
Viruses
Recommended

Use sensitive and specific

tests.
Can modify clinical
Positive influenza test
decision making in children
may decrease the need
with suspected pneumonia;
for additional tests and
antibiotics are not required
antibiotic use, while
in the absence of findings
guiding the use of
that suggest bacterial
antiviral agents in both
co-infection.
outpatient and inpatient
settings.

Strong

Weak

High

Low

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Complete Blood Count

Recommendation
Outpatient
Recommendati
on
Comments

Strength
Evidence
Quality

Inpatient

NOT Recommended

NOT Recommended

However, 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.

Weak

Weak

Low

Low

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Complete Blood CountRationale

Anemia and thrombocytopenia may suggest
hemolytic-uremic syndrome.
o Rarely an occult process.

WBC count has poor specificity for diagnosis

of bacterial pneumonia.
o WBC elevated in many children with CAP.
o Most children with elevated WBC do not have CAP.
o WBC does not reliably distinguish bacterial from
viral CAP.
Waters AM. J Pediatr. 2007; Banerjee R. Pediatr Infect Dis J. 2011; Korppi M. Eur Respir J.
1997

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Antibiotic ChoiceOutpatient
Age of Child
Recommendati
on
Comments

Strength
Evidence
Quality

Infant / Preschool-Age
No
antibiotics
Antibiotics
NOT routinely
required
because viral
pathogens
are most
prevalent.

School-Age
Azithromyc
in

Amoxicillin

Amoxicillin

First-line
therapy if
previously
healthy and
immunized.

First-line
For
therapy if treatment of
previously
older
healthy and
children
immunized. with findings
compatible
Consider
with CAP
atypical
caused by
bacterial
atypical
pathogens. pathogens.

Strong

Provides
excellent
coverage for
S.
pneumoniae.
Strong

High

Moderate

Strong

Weak

Moderate

Moderate

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Antibiotic ChoiceOutpatient
Alternatives
Allergy
Amoxicillin
Azithromycin
Alternatives

2nd/3rd generation
Cephalosporin
Clindamycin
Levofloxacin

Doxycycline (>7 years

old)
Levofloxacin or
Moxifloxacin

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Antibiotic ChoiceInpatient

Recommendati
on
Comments

First Line

Second Line

Ampicillin / PCN G

3rd Generation
Cephalosporin

Immunized infant,
preschool, or school-age
child.

Strength
Evidence

Non-immunized, in
regions with high levels
of PCN resistant
pneumococcal strains, or
in children with lifethreatening infection.
Non-beta lactam agents
(e.g., vancomycin) are
not needed for the
treatment of
pneumococcal
pneumonia.

Strong

Weak

Moderate

Weak

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Antibiotic ChoiceInpatient

Atypical
Secondary Agents
S. aureus
Bacteria

Recommendati
on
Comments

Recommendati
on
Strength
Evidence

Macrolide

Vancomycin or
Clindamycin

In addition to betaIn addition to betalactam therapy if

lactam therapy if
atypical bacteria are clinical, laboratory, or
significant
imaging
considerations.
characteristics are
Instead of beta-lactam
consistent with
if findings are
infection caused by S.
characteristic of
aureus.
atypical infection.
Weak

Strong

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Antibiotic ChoiceRationale
S. pneumoniae remains most common bacterial
cause of CAP
Decreasing S. pneumoniae antibiotic resistance
o >50% decrease in penicillin-non-susceptible infections
o >50% decrease strains in resistance to multiple
antibiotics

Kyaw MH. N Engl J Med. 2006

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Antibiotic ChoiceRationale
Penicillin resistance is not associated with
treatment failure for non-CNS S. pneumoniae
infections.
o In vitro, bactericidal activity achieved at low
concentrations relative to MIC
o In vivo, high and sustained concentrations
achieved in serum and lung
Amoxicillin administered at 80 mg/kg/day
Ampicillin administered at 300 mg/kg/day

Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Perez-Trallero E. J
Chemother. 2001

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Antibiotic ChoiceRationale
Macrolide resistance and 2nd generation
cephalosporin resistance are associated with
treatment failure for non-CNS S. pneumoniae
infections.
Vancomycin
o Not necessary for S. pneumoniae
o MRSA less common and rarely occult
o Challenges
Poor lung penetration compared with aminopenicillins
Associated with nephrotoxicity
May require monitoring trough concentrations or continuous
infusion
Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Chung J. Anaesth Intensive
Care. 2011

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Minimizing ResistanceDuration
Treatment
for the shortest effective duration will
of
Therapy

minimize exposure of both pathogens and normal

microbiota, and minimize the selection for resistance.
Strong recommendation; Low-quality evidence
Treatment courses of 10 days have been best studied.
Shorter courses may be just as effective, particularly for
more mild disease managed on an outpatient basis.
Strong recommendation; Moderate-quality evidence
Infections caused by certain pathogens, notably CA-MRSA,
may require longer treatment than those caused by S.
pneumoniae.
Strong recommendation; Moderate-quality evidence

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Final Thoughts

Guidelines are only as good as the

evidence on which they are based.

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Final Thoughts

Developing guidelines is relatively easy

compared to implementing them.

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Outpatient Bottom Line

Test

Should I do
Comment
it?

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

CBC

No

Yes, if deterioration or no
improvement

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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.

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Inpatient Bottom Line

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

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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!
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