1. Highlights of the PIDS/IDSA National GuidelinesTM
Prepared for your next patient.
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
Cincinnati Children's Hospital Medical Center
Welcome slide for use during audience walk-in.

2. 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 presenter’s 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.
Session agenda

3. 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:
National Institute of Allergy and Infectious Diseases
Agency for Healthcare Research and Quality
Children’s Hospitals Association
Robert Wood Johnson Foundation
Session agenda

4. 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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5. Why Do We Need Guidelines?
Role of guidelines
Assist in healthcare decision-making
Reduce variation in clinical practice
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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6. Context for the US Guidelines
CAP is the most common serious childhood infection in the US.
3 million outpatient visits each year
>150,000 hospitalizations each year
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.
Session agenda
Kronman MP. Pediatrics. 2011; Shah SS. J Hosp Med. 2011; Lee GE. Pediatrics. 2010; Shah SS. Pediatr Pulmonol. 2010 6

7. Diagnostic Testing for CAP at 43 US Hospitals
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Brogan TV. Pediatr Infect Dis J. 2012 7

8. Diagnostic Testing for CAP at 43 US Hospitals
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9. Diagnostic Testing for CAP at 43 US Hospitals
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10. Treatment for CAP at 43 US Hospitals
Session agenda
Data from Ambroggio LV, et al. Pediatr Infect Dis J. 2012 10

11. Session agenda 11

12. Available Free Online and In Print
Guidelines available at:
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:e25–e76
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;53:617– 630
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13. Consensus Development Based on Evidence
92 recommendations
Consensus development based on evidence
GRADE working group (Grading of Recommendations, Assessment, Development, and Evaluation)
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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14. Evidence-Based Guidelines
Clinical Recommendations
Site of care
Diagnostic testing
Anti-infective treatment
Adjunctive treatment
Management of the child not responding to treatment
Discharge criteria
Prevention
Future research
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15. Evidence-Based Guidelines
Clinical Recommendations
Site of care
Diagnostic testing
Anti-infective treatment
Adjunctive treatment
Management of the child not responding to treatment
Discharge criteria
Prevention
Future research
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16. Outline Diagnostic Testing Anti-Infective Treatment Pulse oximetry
Chest x-ray
Blood culture
Atypical bacteria testing
Viral testing
Complete blood counts
Anti-Infective Treatment
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17. 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
Age 3 months – 18 years
Exclusionary conditions
Immune deficiency
Chronic lung disease (e.g., cystic fibrosis)
Mechanical ventilation
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18. Diagnostic Testing—Pulse 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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19. Initial Chest X-Ray—Recommendation
Outpatient
Inpatient
Recommendation
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.
Strength
Strong
Evidence Quality
High
Moderate
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20. Initial Chest X-Ray—Rationale
Chest x-rays (CXRs) not routinely required for outpatient CAP
CXRs:
Do not reliably distinguish bacterial from viral CAP or among the various bacterial pathogens
Impractical in office setting
Often requires travel to a separate facility
Barriers to physicians obtaining timely results
CXR in outpatient setting infrequently changes clinical management
Guideline provides guidance on when to perform CXR in outpatient setting
Session agenda
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 20

21. Repeat Chest X-Ray—Recommendation
Outpatient AND Inpatient
Recommendation
NOT Recommended
Comments
Not routinely indicated in children who recover uneventfully
Recommendation Strength
Strong
Evidence Quality
Moderate
Inpatient and outpatient alike. 21

22. Repeat Chest X-Ray—Recommendation
Outpatient AND Inpatient
Recommendation
Recommended
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 Quality
Moderate
Low
Inpatient and outpatient alike. 22

23. Repeat Chest X-Ray—Rationale
Repeat CXRs commonly identify persistent or residual abnormalities 3–6 weeks later.
Abnormalities rarely alter management.
Abnormalities do not predict treatment failure or worse clinical outcome.
Repeat CXRs represent unnecessary radiation exposure to infants and children.
Session agenda
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 23

24. Blood Cultures―Recommendations
Outpatient
Inpatient
Recommendation
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 
Strength
Strong
Evidence Quality
Moderate
Low
Session agenda 24

25. Blood Cultures—Rationale
Outpatient
Infrequently identifies pathogens (<2%)
False-positives more common than true positives at some hospitals
Rarely informs outpatient management
Session agenda
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 25

26. Blood Cultures—Rationale
Outpatient
Infrequently identifies pathogens (<2%)
False-positives more common than true positives at some hospitals
Rarely informs outpatient management
Inpatient
Positive in ~3% of uncomplicated pneumonia
Positive in ~15% with empyema
Allows for culture-directed therapy when positive
Provides local epidemiologic data
Session agenda
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 26

27. Atypical Bacteria Testing―Recommendation
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Recommendation
Recommended
NOT 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.
Strength
Weak
Strong
Evidence Quality
Moderate
High
Session agenda 27

28. Atypical Bacteria Testing―Rationale
Evolving understanding of M. pneumoniae epidemiology
Increasingly identified in younger children
Rapid tests (IgM and PCR) available
Variable test accuracy
Treatment is not mandatory, especially with low likelihood of infection (e.g., negative test), as benefit of macrolide antibiotics uncertain
Session agenda
Heiskanen-Kosma T. Pediatr Infect Dis J. 1998; Michelow IC. Pediatrics. 2004; Korppi M. Respirology. 2004; Thurman KA. Clin Infect Dis. 2009 28

29. Viral Testing―Recommendations
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.
Strength
Strong
Weak
Evidence Quality
High
Low
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30. Diagnostic Testing—Viral 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
Session agenda 30

31. Viral Testing—Rationale
Influenza testing
Positive tests reduce antibiotic use and ancillary testing (e.g., CXR, CBC) by >50%.
Positive tests guide antiviral treatment decisions.
Early treatment improves outcomes.
Session agenda
Bonner AB. Pediatrics. 2003; Esposito S. Arch Dis Child. 2003; Iyer SB. Acad Emerg Med. 2006; Benito-Fernandez J. Pediatr Infect Dis J. 2006 31

32. Viral Testing—Recommendations
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.
Strength
Strong
Weak
Evidence Quality
High
Low
Session agenda 32

33. Complete Blood Count—Recommendation
Outpatient
Inpatient
Recommendation
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.
Strength
Weak
Evidence Quality
Low
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34. Complete Blood Count—Rationale
Anemia and thrombocytopenia may suggest hemolytic-uremic syndrome.
Rarely an occult process.
WBC count has poor specificity for diagnosis of bacterial pneumonia.
WBC elevated in many children with CAP.
Most children with elevated WBC do not have CAP.
WBC does not reliably distinguish bacterial from viral CAP.
Session agenda
Waters AM. J Pediatr. 2007; Banerjee R. Pediatr Infect Dis J. 2011; Korppi M. Eur Respir J. 1997 34

35. Antibiotic Choice—Outpatient
 Age of Child
Infant / Preschool-Age
School-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.
Strength
Strong
Weak
Evidence Quality
High
Moderate
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36. Antibiotic Choice—Outpatient Alternatives
Allergy
Amoxicillin
Azithromycin
Alternatives
2nd/3rd generation Cephalosporin
Clindamycin
Levofloxacin
Doxycycline (>7 years old)
Levofloxacin or Moxifloxacin
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37. Antibiotic Choice—Inpatient
First Line
Second Line
Recommendation
Ampicillin / PCN G
3rd 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.
Strength
Strong
Weak
Evidence Quality
Moderate
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38. Antibiotic Choice—Inpatient Secondary Agents
Atypical Bacteria
S. aureus
Recommendation
Macrolide
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.
Strength
Weak
Strong
Evidence Quality
Moderate
Low
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39. Antibiotic Choice—Rationale
S. pneumoniae remains most common bacterial cause of CAP
Decreasing S. pneumoniae antibiotic resistance
>50% decrease in penicillin-non-susceptible infections
>50% decrease strains in resistance to multiple antibiotics
Session agenda
Kyaw MH. N Engl J Med. 2006 39

40. Antibiotic Choice—Rationale
Penicillin resistance is not associated with treatment failure for non-CNS S. pneumoniae infections.
In vitro, bactericidal activity achieved at low concentrations relative to MIC
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
Session agenda
Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Perez-Trallero E. J Chemother. 2001 40

41. Antibiotic Choice—Rationale
Macrolide resistance and 2nd generation cephalosporin resistance are associated with treatment failure for non-CNS S. pneumoniae infections.
Vancomycin
Not necessary for S. pneumoniae
MRSA less common and rarely “occult”
Challenges
Poor lung penetration compared with aminopenicillins
Associated with nephrotoxicity
May require monitoring trough concentrations or continuous infusion
Session agenda
Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Chung J. Anaesth Intensive Care. 2011 41

42. Minimizing Resistance―Duration 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.
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43. Guidelines are only as good as the evidence on which they are based.
Final Thoughts
Guidelines are only as good as the evidence on which they are based.
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44. Final Thoughts
Developing guidelines is relatively easy compared to implementing them.
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45. Outpatient Bottom Line
Test
Should I do it?
Comment
Pulse oximetry
Yes
CXR No
Consider in some circumstances
Repeat CXR
Influenza testing
During influenza season
Mycoplasma
Encouraged if considering macrolide
Sputum
Blood culture
Yes, if deterioration or no improvement
CBC
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46. Outpatient Bottom Line
Role
Antibiotic
Comment
First-Line
Amoxicillin
Alternate
2nd/3rd generation cephalosporin; clindamycin; levofloxacin
Macrolide
Add to include coverage for atypicals.
Substitute to include coverage for atypicals if pneumococcal coverage is not desired.
Session agenda 46

47. Inpatient Bottom Line Test Should I do it? Comment Pulse oximetry Yes
CXR
Repeat CXR No
Consider in some circumstances
Influenza testing
During influenza season
Mycoplasma
Encouraged if considering macrolide
Sputum
If child can provide
Blood culture
CBC
Session agenda 47

48. Inpatient Bottom Line Role Antibiotic Comment First-Line Ampicillin
Alternate
Cefotaxime or Ceftriaxone
If unimmunized
Macrolide
Add to include coverage for atypicals.
Substitute to include coverage for atypicals if pneumococcal coverage is not desired.
Session agenda 48

49. Thank You!
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