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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 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: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

Evidence
92 recommendations
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 Site of care
o Diagnostic testing
o Anti-infective treatment
o Adjunctive treatment
o 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 Site of care
o Diagnostic testing
o Anti-infective treatment
o Adjunctive treatment
o Management of the child not responding to
treatment
o Discharge criteria
o Prevention
Future research
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Outline
Diagnostic Testing
o Pulse oximetry
o Chest x-ray
o Blood culture
o Atypical bacteria testing
o Viral testing
o 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 Recommended
Comments In all children with
pneumonia and suspected
hypoxemia.

The presence of hypoxemia

should guide decisions and
further diagnostic testing.
Recommendation
Strength
Strong
Evidence Quality Moderate
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Initial Chest X-Ray

Recommendation
Outpatient Inpatient
Recommendati NOT
on
Recommended 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 Strong Strong Strong
Evidence
Quality
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 NOT Recommended
Comments
Not routinely indicated in
children who recover
uneventfully
Recommendation
Strong
Strength
Evidence Quality Moderate
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Repeat Chest X-Ray

Outpatient AND Inpatient
Recommendation
Recommendation Recommended Recommended Recommended
Comments
For inadequate In children with 46 weeks after
clinical complicated the diagnosis of
improvement, pneumonia with CAP in limited
progressive worsening circumstances
symptoms, or respiratory (e.g., recurrent
clinical distress or pneumonia in
deterioration clinical instability same lobe or
within 4872 suspicion of an
hours after anatomic
initiation of anomaly)
antibiotics
Recommendation
Strong Strong Strong
Strength
Evidence Quality 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

Outpatient Inpatient
Recommendati NOT Recommende Recommend
on
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 Strong Strong Strong
Evidence
Quality Moderate Moderate 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 Positive in ~3% of uncomplicated pneumonia
o Positive in ~15% with empyema
o Allows for culture-directed therapy when positive
o 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
TestingRecommendation

Mycoplasma Chlamydophila
pneumoniae pneumoniae
Recommendati NOT
on
Recommended
recommended
Comments
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.
Strength Weak Strong
Evidence
Quality
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

Other Respiratory
Influenza
Viruses
Recommendati
on
Recommended Recommended
Comments 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.
Strength Strong Weak
Evidence
High Low
Quality
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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

Other Respiratory
Influenza
Viruses
Recommendati
on Recommended Recommended
Comments 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.
Strength Strong Weak
Evidence
High Low
Quality
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Complete Blood Count

Recommendation
Outpatient Inpatient
Recommendati
NOT Recommended NOT Recommended
on
Comments However, may provide However, may provide
useful useful information for
information in those with those with severe
more serious disease for pneumonia; to be
clinical management in the interpreted in the context
context of clinical exam of clinical exam and other
and other laboratory and laboratory and imaging
imaging studies. studies.
Strength Weak Weak
Evidence
Low Low
Quality
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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 Infant / Preschool-Age School-Age
Recommendati No Azithromyc
Amoxicillin Amoxicillin
on antibiotics in
Comments
Antibiotics First-line First-line For
NOT routinely therapy if therapy if treatment of
required previously previously older
because viral healthy and healthy and children
pathogens immunized. immunized. with findings
are most compatible
prevalent. Provides Consider with CAP
excellent atypical caused by
coverage for bacterial atypical
S. pathogens. pathogens.
pneumoniae.
Strength Strong Strong Strong Weak
Evidence
High Moderate Moderate Moderate
Quality
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Antibiotic ChoiceOutpatient
Alternatives
Allergy Amoxicillin Azithromycin
Alternatives
2nd/3rd generation Doxycycline (>7 years
Cephalosporin old)
Clindamycin Levofloxacin or
Levofloxacin Moxifloxacin
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Antibiotic ChoiceInpatient
First Line Second Line
Recommendati 3rd Generation
Ampicillin / PCN G
on Cephalosporin
Comments Non-immunized, in
regions with high levels
of PCN resistant
pneumococcal strains, or
in children with life-
Immunized infant, threatening infection.
preschool, or school-age
child. Non-beta lactam agents
(e.g., vancomycin) are
not needed for the
treatment of
pneumococcal
pneumonia.
Strength Strong Weak
Evidence
Moderate Weak
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Antibiotic ChoiceInpatient
Secondary Agents

Atypical
S. aureus
Bacteria
Recommendati Vancomycin or
Macrolide
on Clindamycin
Comments
In addition to beta- In addition to beta-
lactam 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.
Recommendati
on Weak Strong
Strength
Evidence
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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
of Therapy
Treatment for the shortest effective duration will
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

Should I do
Test 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 Yes, if deterioration or no
improvement
CBC No
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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

Should I do
Test Comment
it?
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 If unimmunized
Ceftriaxone
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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