This document provides guidelines for the classification, diagnosis, treatment, and prevention of pediatric community-acquired pneumonia (PCAP). It classifies PCAP into 4 categories (A-D) based on risk factors and clinical severity. It recommends empiric antibiotic treatment based on category and diagnostic testing. It also provides guidance on evaluating treatment response and switching between IV and oral antibiotics. Ancillary treatments, prevention strategies, and management of treatment failure are also outlined.
This document provides guidelines for the classification, diagnosis, treatment, and prevention of pediatric community-acquired pneumonia (PCAP). It classifies PCAP into 4 categories (A-D) based on risk factors and clinical severity. It recommends empiric antibiotic treatment based on category and diagnostic testing. It also provides guidance on evaluating treatment response and switching between IV and oral antibiotics. Ancillary treatments, prevention strategies, and management of treatment failure are also outlined.
This document provides guidelines for the classification, diagnosis, treatment, and prevention of pediatric community-acquired pneumonia (PCAP). It classifies PCAP into 4 categories (A-D) based on risk factors and clinical severity. It recommends empiric antibiotic treatment based on category and diagnostic testing. It also provides guidance on evaluating treatment response and switching between IV and oral antibiotics. Ancillary treatments, prevention strategies, and management of treatment failure are also outlined.
This document provides guidelines for the classification, diagnosis, treatment, and prevention of pediatric community-acquired pneumonia (PCAP). It classifies PCAP into 4 categories (A-D) based on risk factors and clinical severity. It recommends empiric antibiotic treatment based on category and diagnostic testing. It also provides guidance on evaluating treatment response and switching between IV and oral antibiotics. Ancillary treatments, prevention strategies, and management of treatment failure are also outlined.
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PCAP GUIDELINES
Etiology Outpatient and in-patients: bacterial > viral For bacterial: Streptoccocus pneumoniae> H. influenzae> Mycoplasma sp.> Chlamydia sp.
Risk Classification Variables Co-morbids Compliant Caregiver Ability to Follow up Dehydration Feeding Age RR 2-12 mos 1-5 yrs > 5 yrs PCAP A Minimal None + + None Yes > 11 months > Or = 50 > Or = 40 > Or = 30 PCAP B Low + + + Mild Yes > 11 months > 50 > 40 > 30 PCAP C Moderate + None None Moderate No < 11 months > 60 > 50 > 35 PCAP D High + None None Severe No < 11 months > 70 > 50 > 35
Variables Retractions Head bobbing Cyanosis Grunting Apnea Sensorium
PCAP A Minimal
PCAP B Low
PCAP C Moderate Intercostal/ subcostal + +
PCAP D High Supraclavicular + + + +
Awake
Awake
Irritable
Lethargic/ stuporous/ comatose + Admit to ICU Refer to specialist
Complications Action OPD Follow up at end of treatment OPD Follow up after 3 days
+ Admit to wards
Diagnostics No diagnostic aids initially requested for PCAP A or B managed on an outpatient basis Routine exams for PCAP C or D: CXR PAL WBC count CS: blood (for PCAP D), pleural fluid, ETA upon intubation Blood gas/O2 sat
Diagnostics Sputum CS for older children ESR and CRP are not routinely requested
Predictors of bacterial pathogen
Clinical prediction using a bacterial pneumonia score BPS 4 ~ (+) bacterial pathogen in hospitalized patients 1 month 5 years
Probable organisms acc. to age
Increase age, higher chance of bacterial pathogen, increasing frequency of atypical organism
Decreased breath sounds
Treatment Antibiotics are recommended in: 1. Patients classified as either PCAP A or B and is: (a) beyond 2 years of age; or (b) having high grade fever without wheeze 2. Patients classified as PCAP C and is: (a) beyond 2 years of age; (b)having high grade fever without wheeze; (c) having alveolar consolidation in chest x-ray; (d) or having WBC count > 15,000 3. Patients classified as PCAP D
Treatment Empiric treatment (bacterial etiology): PCAP A or B w/o previous antibiotic: Amoxicillin 45 mg/kg/day in 3 divided doses x 3 days (min) Macrolide if w/ hypersensitivity of amoxicillin Other regimens: Co-trimoxazole, azithromycin, erythromycin, co-amoxiclav, clarithromycin
PCAP C w/o previous antibiotic and has complete immunization against Hib: Penicillin G 100,000 u/kg/day Oral amoxicillin in patients who can tolerate feeding (comparable to parenteral penicillin)
Treatment Empiric treatment (bacterial etiology): PCAP C w/o Hib immunization: IV ampicillin 100 mg/kg/day in 4 divided doses Monotherapy (parenteral ampicillin) or combination therapy (IV penicillin + chloramphenicol) in patients who cannot tolerate feeding Other regimens: Amoxicillin/sulbactam, cefuroxime, chloramphenicol
PCAP D: consult a specialist
Treatment If CA-MRSA suspected, refer immediately to the appropriate specalist. Strategies in clinical management of MRSA: Follow antibiotic susceptibility based on culture studies Vancomycin remains to be the 1st line therapy for severe infections possibly caused by MRSA CA-MRSA were more likely to be synergistically inhibited by vancomycin + gentamicin vs. vancomycin alone
Treatment Initial treatment (viral etiology): Ancillary treatment Oseltamivir 2 mg/kg/dose BID x 5 days may be given for laboratory confirmed influenza
Response to antibiotics Decrease in respiratory signs (i.e. tachypnea) and defervescense within 72 hours after initiation of antibiotic FAVORABLE Nonsevere: RR>5 bpm slower than baseline Severe: defervescense, decrease in tacypnea & chest indrawing, increase in O2 sat & ability to feed within 48 hours
Persistence of symptoms beyond 72 hours after initiation of antibiotics RE-EVALUATE
Response to antibiotics Improved: RR < age-specific range without chest indrawing or any danger signs (central cyanosis, inability to drink, abnormally sleepy or convulsions) Treatment failure Same: RR > age-specific range WITHOUT chest indrawing or any danger signs Worse: Developed chest indrawing or any of the danger signs
Response to antibiotics If a patient w/ PCAP A or B is not responding to antibiotics w/in 72 hours, consider: Change the initial antibiotic; or Start an oral macrolide; or Re-evaluate diagnosis
Causes of treatment failure: co-infection w/ RSV, non-adherence to treatment
Response to antibiotics If a patient w/ PCAP C is not responding to antibiotics w/in 72 hours, consider: Penicillin resistant Strep pneumoniae; or Presence of pulmonary or extrapulmonary complications; or Other diagnosis
Response to antibiotics If a patient w/ PCAP D is not responding to antibiotics w/in 72 hours, consider: Immediate re-consultation w/ a specialist
Response to antibiotics Switch from IV to oral 2-3 days after initiation of antibiotics recommended if: Responding to the initial antibiotic therapy Able to feed w/ intact GI absorption Without pulmonary or extrapulmonary complications
Switch from 3 days of IV ampicillin to 4 days of amoxicillin (preferred) or cotrimoxazole
Ancillary treatment Oxygen and hydration if needed among inpatients Cough preparations, chest physiotherapy, pNSS nebulization, steam inhalation, topical solution, bronchodilators are not routinely used A bronchodilator may be used if with wheezing
Prevention Pneumococcal and Hib vaccination Zinc supplementation may be administered to prevent pneumonia Handwashing using antibacterial soaps Breastfeeding
