MIAMI BEACH – With 92 recommendations and 340 references that span 51 pages, clinical practice guidelines for management of infants and children with community-acquired pneumonia might at first seem overwhelming, but they are worth consideration, according to Dr. Mary Anne Jackson.
"Don’t be daunted about getting into it. It actually divides out pneumonia in ways that will be relevant to your particular practice," she said.
Dr. Mary Anne Jackson
The guidelines address management of otherwise healthy children with community-acquired pneumonia (CAP) – not hospital-acquired – in both the outpatient and inpatient settings (Clin. Infect. Disease 2011;53:e25-76). "This is the first time the Pediatric Infectious Diseases Society has been asked to make pediatric-specific recommendations. This is a big step," Dr. Jackson said.
The clinical practice guidelines, developed in conjunction with the Infectious Disease Society of America, address "looking at a child with signs and symptoms and being able to predict pneumonia," said Dr. Jackson, chief of the pediatric infectious diseases section at Children’s Mercy Hospitals and Clinics in Kansas City.
Nasal flaring in an infant less than 12 months, for example, had the best positive predictive value. Oxygen saturation less than 94% at sea level "is also clearly predictive," she said. Less surprising predictors include tachypnea and retractions. In contrast, absence of tachypnea or other respiratory signs had the best negative predictive value.
Also addressed within the scope of the evidence-based guidelines are site of care, use of diagnostic testing, appropriate initial anti-infective treatment, adjunctive therapy, management of a child unresponsive to therapy, appropriate discharge criteria, and prevention of community-acquired pneumonia.
"Let’s look at a little of the guidelines and see how these recommendations might influence your practice," Dr. Jackson said at a pediatric update sponsored by Miami Children’s Hospital.
Blood cultures are not necessary for the nontoxic, immunized child who is going to be managed as outpatient, for example. "The guidelines will tell you that less than 1% of the individuals who meet these guidelines will have a positive blood culture if they have been effectively immunized," said Dr. Jackson, who was not one of the 13 authors of the guidelines.
Blood cultures, however, are indicated for the infant or child who requires hospital admission or who has evidence of empyema. An estimated 14%- 27% of children with a complicated pneumonia will have a positive blood culture, she said. "This will help you decide about anti-infective therapy [and] help you provide definitive therapy."
In terms of diagnostic testing, radiography should be obtained for the child sick enough to be admitted to the hospital, for the child who is hypoxic with significant respiratory distress, for the child with an infection that is prolonged or unresponsive, and "certainly if you suspect an empyema."
Think empyema when you suspect CAP, particularly in the setting of prolonged or recurrent fever, Dr. Jackson said. Patients with empyema often report chest and abdominal pain as well. Check their medication history too, she advised. "They may have received azithromycin, which I will tell you is not a good choice for pneumococcal infection or respiratory infection in general (unless you suspect Mycoplasma pneumoniae) in the pediatric population."
The guideline authors outline scenarios where hospitalization is recommended. For example, admission is indicated for suspected bacterial pneumonia in children aged 3-6 months of age or any infant or any child who is not fully immunized, who has oxygen saturation below 90%, or who cannot comply with oral therapy.
Admission is also supported for suspected methicillin-resistant Staphylococcus aureus (MRSA) infection. "I have a very high index of suspicion in the sick infant (particularly those under 1 year of age) with bacterial pneumonia [with] MRSA as a pathogen," Dr. Jackson said.
The guidelines also outline antibiotic treatment. Treatment is generally 10 days for CAP or longer with empyema.
The previously healthy and immunized preschool age child treated as an outpatient should receive amoxicillin, the guideline authors stated. They prefer clindamycin for penicillin-allergic patients but offer alternative options. "You should check your antibiogram in your own institution so you know what your clindamycin resistance rates are for pneumococcus," Dr. Jackson said.
In the inpatient setting, an immunized infant or child with CAP can be treated with ampicillin or penicillin G. "Once again, you must know what your local rates of penicillin resistance are in your institution," she said.
Empiric therapy with a third generation parenteral cephalosporin such as ceftriaxone or cefotaxime is recommended for hospitalized infants and children who are not fully immunized in regions with a higher penicillin resistance rate or for children with a life-threatening infection. "I will tell you in those instances you are going to have a higher risk of staphylococcal infection, and ceftriaxone and cefotaxime lack staphylococcal coverage," Dr. Jackson said. "So you’re going to have to broaden your coverage for those patients."