PRACTICE RECOMMENDATIONS
• Chest x-rays and lab testing may be optional for children with community-acquired pneumonia (CAP) who are not seriously ill. A
• Start amoxicillin empirically for any child with mild-to-moderate CAP. B
• If an atypical bacterial pneumonia is suspected, azithromycin is the first-line treatment. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
What are the recommended antibiotic choices for children with mild-to-moderate bacterial community-acquired pneumonia (CAP) in the outpatient setting? How much diagnostic testing is required? When might hospitalization and combination antibiotic therapy be warranted?
Evidence-based answers to these and other questions relevant to the management of CAP in infants and children older than 3 months are provided in a set of guidelines jointly published by the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS) in 2011.1 We summarize them here.
What the guidelines do, and don’t, address
The IDSA/PIDS guidelines, which focus on the care of otherwise healthy children with CAP in both outpatient and inpatient settings, seek to decrease morbidity and mortality rates associated with this respiratory infection. The guidelines do not apply to children younger than 3 months, immunocompromised patients, children receiving home mechanical ventilation, or children with chronic conditions or underlying lung disease, such as cystic fibrosis.
The need for evidence-based guidance. Globally each year, 1.5 million children 5 years of age and younger suffer a pneumonia-related death, particularly in developing countries.2-5 This is more than the number of deaths associated with any other disease in the world, including acquired immune deficiency syndrome (AIDS), tuberculosis (TB), or malaria.2 In 2010, pneumonia was ranked in the United States as the sixth leading cause of death for children one to 4 years of age and the 10th leading cause of death in adolescents.5 It is estimated that out of every 1000 infants and children in North America and Europe, 35 to 40 will be affected by CAP.2
How the guidelines define CAP. Pneumonia can be broadly defined as a lower respiratory tract infection, but definitions vary depending on the organization, institution, or health care setting. For instance, the World Health Organization (WHO) defines pneumonia solely on the basis of clinical findings obtained by visual inspection and timing of the respiratory rate.6 Another definition published by Bone and colleagues states that pneumonia is the “inflammation of the pulmonary parenchyma brought about by the presence of virulent pathogens; usually differentiated from isolated infections of the major airways.”7 The new pediatric guidelines define CAP as “the presence of signs and symptoms of pneumonia in a previously healthy child caused by an infection that has been acquired outside the hospital.”1
CAP pathogens vary with the child’s age
Typically, diagnostic testing of children will reveal several microbes, viral and bacterial, making it difficult to determine which might be the pathogen.1 Viral pathogens are more common causes of CAP in children younger than 2 years, accounting for 80% of cases1; bacterial pathogens are more common in older children.1
The virus detected most often among children younger than 2 years is respiratory syncytial virus (RSV).1,8-12 Less common viruses include adenovirus, influenza types A and B, parainfluenza 1, 2, and 3, and rhinovirus. Streptococcus pneumoniae is the most common bacterial pathogen identified in older children.1,13 The overall incidence of pneumonia decreases with age, but it has been reported that the proportion of cases from atypical bacterial pathogens—Chlamydia pneumoniae and Mycoplasma pneumoniae—may increase among older children.1,13
Signs and symptoms also vary
Signs and symptoms of CAP differ depending on the severity of the infection and the age of the child. In general, respiratory distress (tachypnea, nasal flaring, decreased breath sounds, cough, and rales) with fever are the prominent symptoms associated with pneumonia.1,13,14
Infants and children with mild to moderate infection most commonly exhibit a temperature <38°C and a respiratory rate <50 breaths per minute (bpm).
Children with severe CAP commonly present with a temperature >38°C, flaring of nostrils, grunting with breathing, tachypnea, tachycardia, and cyanosis. Tachypnea is defined as >60 bpm in infants younger than 2 months, >50 bpm in infants 2 to 12 months, and >40 bpm in children ages 1 to 5 years.8 Although respiratory rate is a valuable clinical sign, the work of breathing (as evidenced by nasal flaring, breathlessness, cough, or wheeze) required by the infant or child may be more indicative of pneumonia.15
Utilize diagnostic testing judiciously
Not all patients with suspected CAP require the same amount of diagnostic testing. In fact, IDSA/PIDS recommendations vary for hospitalized patients and for outpatients.1 In all cases, conduct testing quickly to expedite diagnosis and minimize the need for additional testing, to help validate treatment choices, and to reduce time spent in the hospital.1