Community Acquired Pneumonia Dr Sanjay Lalwani Vice Principal Professor and Head Department Pediatrics BVUMC, Pune 26/07/2015

Clinical recommendations Site-of-Care Diagnostic Testing Anti-Infective Treatment Adjunctive Surgical and Non–Anti-infective Therapy for Pediatric CAP Management in the Child Not Responding to Treatment Discharge Criteria Prevention

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

Site-of-Care Management Decisions Diagnostic Testing for Pediatric CAP Anti-Infective Treatment Adjunctive Surgical and Non–Anti-infective Therapy for Pediatric CAP Management in the Child Not Responding to Treatment Discharge Criteria Prevention

Hospitalization Indications Children and infants who have moderate to severe CAP Infants,3–6 months of age with suspected bacterial CAP Children and infants with a suspicion or documentation of CAP caused by MRSA Concern about careful observation at home or who are unable to comply with therapy or unable to be followed up should be hospitalized.

WHO-Pneumonia definition Pneumonia -cough or difficult breathing and age- adjusted tachypnea: (age 2–11 months, >50/min; 1–5 years, >40/min; >5 years, >20 breaths/min) Severe pneumonia - cough or difficulty breathing plus one of the following: lower chest indrawing, nasal flaring, or grunting Very severe pneumonia -cough or difficulty breathing plus one of the following: cyanosis, severe respiratory distress, inability to drink or vomiting everything, lethargy, unconsciousness/convulsions

Criteria for ICU admission Requiring ventilation child has sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion. Pulse oximetry measurement is 0.50 Child has altered mental status

Site-of-Care Management Decisions Diagnostic Testing for Pediatric CAP Anti-Infective Treatment Adjunctive Surgical and Non–Anti-infective Therapy for Pediatric CAP Management in the Child Not Responding to Treatment Discharge Criteria Prevention

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

Diagnostic Testing—Pulse Oximetry Outpatient and inpatient RecommendationRecommended Comments In all children with pneumonia and suspected hypoxemia. The presence of hypoxemia should guide decisions and further diagnostic testing. Recommendation strength Strong Evidence QualityModerate

Initial Chest X-Ray—Recommendation OutpatientInpatient Recommendatio n Not Recommended Recommended Comments For confirmation of suspected CAP in patient well enough to be treated in outpatient setting (after evaluation in office, clinic, or ED). Patients with hypoxemia, significant respiratory distress, and failed antibiotic therapy; to verify presence or absence of complications All patients hospitalized with CAP; to document presence, size, and character of infiltrates and identify complications that may require interventions Recommendatio n strength Strong Evidence Quality HighModerate

Repeat Chest X-Ray—Recommendation Outpatient and Inpatient RecommendationNot Recommended Comments Not routinely indicated in children who recover uneventfully Recommendation strength Strong Evidence QualityModerate

Repeat Chest X-Ray—Recommendation Outpatient and Inpatient RecommendationRecommended Comments For inadequate clinical improvement, progressive symptoms, or clinical deterioration within 48–72 hours after initiation of antibiotics In children with complicated pneumonia with worsening respiratory distress or clinical instability 4–6 weeks after the diagnosis of CAP in limited circumstances (e.g., recurrent pneumonia in same lobe or suspicion of an anatomic anomaly) Recommendation strength Strong Evidence QualityModeratelowModerate

Blood culture —Recommendation OutpatientInpatient Recommendat ion Not Recommended Recommended Comments Non-toxic, fully immunized children treated as outpatients Failure to demonstrate clinical improvement, progressive symptoms, or deterioration after initiation of antibiotic therapy Requiring hospitalization for moderate- severe bacterial CAP Recommendat ion strength Strong Evidence Quality Moderate Low

Atypical bacteria testing Mycoplasma pneumoniae Chlamydophila pneumoniae Recommendation RecommendedNOT recommended Comments If signs/symptoms consistent with but not classic for Mycoplasma; can help guide antibiotic selection. Reliable and readily available diagnostic tests do not currently exist. Recommendation strength WeakStrong Evidence Quality Moderate High

Viral testing Influenza Other Respiratory Viruses Recommendation Recommended Comments Use sensitive and specific tests. Positive influenza test may decrease the need for additional tests and antibiotic use, while guiding the use of antiviral agents in both outpatient and inpatient settings. Can modify clinical decision making in children with suspected pneumonia; antibiotics are not required in the absence of findings that suggest bacterial co-infection. Recommendation strength StrongWeak Evidence Quality High Low

Complete blood count recommendation OutpatientInpatient Recommendatio n NOT Recommended Comments 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. Recommendatio n strength Weak Evidence Quality Low

Antibiotic Choice—Outpatient Age of Child Infant/pre school ageSchool age Recommendation No antibiotics Amoxicillin Azithromycin Comments Antibiotics NOT routinely required because viral pathogens are most prevalent. First-line therapy if previously healthy and immunized. Provides excellent coverage for S. pneumoniae. First-line therapy if previously healthy and immunized. Consider atypical bacterial pathogens. For treatment of older children with findings compatible with CAP caused by atypical pathogens. StrengthStrong Weak Evidence QualityHighModerate

Antibiotic Choice—Outpatient Alternatives AllergyAmoxicillinAzithromycin Alternatives 2 nd /3 rd generation Cephalosporin Clindamycin Levofloxacin Doxycycline (>7 years old) Levofloxacin or Moxifloxacin

Antibiotic Choice—Inpatient First LineSecond Line Recommendatio n Ampicillin / PCN G 3 rd Generation Cephalosporin Comments Immunized infant, preschool, or school-age child. Non-immunized, in regions with high levels of PCN resistant pneumococcal strains, or in children with life-threatening infection. Non-beta lactam agents (e.g., vancomycin) are not needed for the treatment of pneumococcal pneumonia. StrengthStrongWeak Evidence Quality ModerateWeak

Antibiotic Choice—Inpatient Secondary Agents Atypical Bacteria S. aureus RecommendationMacrolide Vancomycin or Clindamycin Comments In addition to beta- lactam therapy if atypical bacteria are significant considerations. Instead of beta- lactam if findings are characteristic of atypical infection. In addition to beta- lactam therapy if clinical, laboratory, or imaging characteristics are consistent with infection caused by S. aureus. Recommendation Strength WeakStrong Evidence QualityModerateLow

Take home message

TestShould I do it?Comment Pulse oximetryYes CXRNoConsider in some circumstances Repeat CXRNoConsider in some circumstances Influenza testing YesDuring influenza season MycoplasmaYesEncouraged if considering macrolide SputumNo Blood cultureNoYes, if deterioration or no improvement CBCNo Outpatient Bottom Line

Outpatient bottom line RoleAntibioticComment First-LineAmoxicillin Alternate2 nd /3 rd generation cephalosporin; clindamycin; levofloxacin AlternateMacrolideAdd to include coverage for atypicals. AlternateMacrolideSubstitute to include coverage for atypicals if pneumococcal coverage is not desired.

TestShould I do it?Comment Pulse oximetryYes CXRYes Repeat CXRNoConsider in some circumstances Influenza testing YesDuring influenza season MycoplasmaYesEncouraged if considering macrolide SputumYesIf child can provide Blood cultureYes CBCNo Inpatient Bottom Line

Inpatient bottom line RoleAntibioticComment First-LineAmpicillin AlternateCefotaxime or Ceftriaxone If unimmunized AlternateMacrolideAdd to include coverage for atypicals. AlternateMacrolideSubstitute to include coverage for atypicals if pneumococcal coverage is not desired.

Thank you