Diagnosis and Management of Community-Acquired Pneumonia in Childhood - SATS Guidelines

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    CONTENTS

    EditorDANIEL J NCAYIYANA

    Deputy EditorJ P DE V VAN NIEKERK

    Assistant EditorEMMA BUCHANAN

    Technical EditorsJULIA CASCIOLAMARIJKE MAREEPAULA VAN DER BIJL

    Senior News JournalistCHRIS BATEMANTel. (021) 530-6537

    Manuscript TrackingREN SEGERSTel. (021) 530-6529

    Head of PublishingEUVRARD LOUBSER

    Production ManagerROBERT ARENDSE

    Production Co-ordinatorEMMA COUZENS

    Projects ManagerBRONWYNNE SCHNIDER

    Professional AdvertisingVANESSA SAMPSONTel. (021) 530-6549E-mail: [email protected]

    DTP & DesignSIOBHAN CAULFIELD

    FAROUK JONESJANINE FESTER

    TypesettingGERTRUDE FANI

    Distribution ManagerEDWARD MACDONALD

    Advertising EnquiriesSALES DIRECTOR: DAVID ITZKINTel. (021) 530-6546SALES MANAGER: DIANE SMITHTel. (021) 481-2082

    Sales TeamPRETORIA: LISA HOFFMAN,TSHEPO MAHLANGUCAPE TOWN: AZAD YUSUF,KEITH HILL

    HMPG Board of DirectorsR E KIRSCH (Chair) J TERBLANCHEN MABASAM LUKHELEM VELLERS VELZEBOER

    Associate EditorsH M COOVADIA (UKZN)D J DU PLESSIS (Pretoria)J IPUTO (Transkei)R E KIRSCH (UCT)B MAYOSI (UCT)H ODENDAAL (Stellenbosch)A D ROTHBERG (Wits)A A STULTING (Free State)C F VAN DER MERWE (Limpopo)

    ISSN 0256-9574

    PRINTED BY TANDYM PRINT

    ABSTRACT 977

    1. INTRODUCTION 977

    2. EVOLUTION OF THE GUIDELINE 9772.1 Aim of the guideline 9772.2 Process of guideline development 977

    3. DEFINITION OF CAP 978

    4. EPIDEMIOLOGY OF CAP 978

    5. AETIOLOGY OF CAP IN CHILDREN 978

    6. DIAGNOSIS OF CAP 9796.1 Clinical evaluation 9796.2 Radiological diagnosis 9796.3 Aetiological diagnosis 979

    7. ANTIBIOTIC USE IN THE TREATMENT OF CAP 9817.1 Route of antibiotic administration 9847.2 Duration of treatment 984

    8. SUPPORTIVE TREATMENT IN THE MANAGEMENT OF CAP 9848.1 Oxygen therapy 984

    8.2 Antipyretics and analgesics 9858.3 Blood transfusions 9868.4 Fluids 9868.5 Nutrition 9878.6 Indications for transfer and admission to a PICU 9878.7 Measures of no value in the treatment of CAP 987

    9. PREVENTION OF CHILDHOOD CAP 9879.1 General preventive strategies 9879.2 Specific preventive strategies 988

    10. ACKNOWLEDGEMENTS 989

    11. WORKING GROUPS OF THE PAEDIATRIC ASSEMBLY OF THESOUTH AFRICAN THORACIC SOCIETY 989

    12. DISCLOSURE STATEMENTS 989

    13. REFERENCES 989

    COMMUNITY-ACQUIRED PNEUMONIA INCHILDHOOD GUIDELINES

    December 2005, Volume 95, No. 12 (Part 2)

    The SAMJ is published on the first of the month by the Health and Medical Publishing

    Group (Pty) Ltd, Co registration 2004/0220 32/07, a subsidiary of SAMA. Suites 1-2, Lonsdale

    Building, Gardener Way, Pinelands, 7405

    All letters and articles for publication should be addressed to the Editor, Private Bag X1,

    Pinelands, 7430. Tel. (021) 530-6520. Fax (021) 531-4126. E-mail: [email protected]

    Website: www.samedical.org

    Copyright: Health and Medical Publishing Group (Pty) Ltd, a subsidiary of the South African MedicalAssociation. This work is copyright under the Berne Convention. It is also copyright in terms of the Copyright

    Act 98 of 1978. No part of this publication may be reproduced, stored in a retrieval system, or transmitted inany form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without permissionof the copyright holder.

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    GUIDELINE

    December 2005, Vol. 95, No. 12 SAMJ

    1. Introduction

    Pneumonia is a major cause of morbidity and mortality inSouth African children,1 and this burden has been exacerbatedby the HIV epidemic. Early and appropriate treatment ofpneumonia can reduce morbidity and mortality,2 which hasbeen the rationale for the development of guidelines for themanagement of community-acquired pneumonia (CAP). Indeveloping these guidelines, consideration has been given tothe high prevalence of HIV infection in South Africa and itsimpact on childhood pneumonia.3 These guidelines have alsotaken into consideration the current policy regarding treatment

    of pneumonia, including recommendations contained in theIntegrated Management of Childhood Illness (IMCI) strategywhich is currently being implemented in South Africa.

    Published guidelines for the management of CAP in childrenhave been developed by the British Thoracic Society4 and theCanadian Medical Association;5 however, there are nopublished guidelines for children in developing countries or inhigh HIV prevalence regions.

    2. Evolution of the guideline

    2.1 Aim of the guideline

    This document aims to provide guidelines for diagnosis andeffective management of children with CAP so as to improvepneumonia-associated morbidity and mortality in South Africa.The guidelines aim to provide recommendations for effectivetherapy and to minimise the development of bacterialresistance through judicious use of antibiotics. The guidelineshave been developed for management of children with simplepneumonia without underlying disease, except for HIVinfection. The guidelines are aimed at children from birth to 12years of age, receiving care at primary, secondary or tertiarycare facilities. These guidelines do not address the treatment ofchildren admitted to a paediatric intensive care unit (PICU),nor do they cover therapy of nosocomial pneumonia.

    2.2 Process of guideline development

    Five subgroups covering different aspects of childhood CAPwere established under the direction of the PaediatricAssembly of the South African Thoracic Society (SATS).Position papers were developed by a group of experts for eachsubgroup in the following areas: (i) epidemiology andaetiology of CAP; (ii) diagnosis of CAP; (iii) antibiotictreatment of CAP; (iv) supportive treatment of CAP; and (v)prevention of CAP.

    Diagnosis and Management of Community-AcquiredPneumonia in Childhood South African Thoracic SocietyGuidelines

    H J Zar, P Jeena, A Argent, R Gie, S A Madhi and the members of the Working Groups of the Paediatric Assembly of the SouthAfrican Thoracic Society

    Correspondence to: Professor Heather Zar, School of Child and

    Adolescent Health, Red Cross Childrens Hospital and University ofCape Town. Tel. (021) 658-5350, fax (021) 689-1287, e-mail:

    [email protected]

    Background. Community-acquired pneumonia (CAP) is a majorcause of morbidity and mortality in South African children.The incidence, severity and spectrum of childhood pneumonia

    have changed owing to the HIV epidemic. Increasingemergence of antimicrobial resistance necessitates a rationalapproach to the use of antibiotics in pneumonia management.

    Objective. To develop guidelines for the diagnosis, managementand prevention of CAP in South African children.

    Methods. The Paediatric Assembly of the South AfricanThoracic Society established five expert subgroups to address:(i) epidemiology and aetiology; (ii) diagnosis; (iii) antibiotictreatment; (iv) supportive therapy; and (v) prevention of CAP.Each subgroup developed a position paper based on theavailable published evidence; in the absence of evidence,

    expert opinion was accepted. After peer review and revision,the position papers were synthesised into an overall guidelinewhich was further reviewed and revised.

    Recommendations. Recommendations based on epidemiologicalfactors include a diagnostic approach, investigations,supportive therapy, appropriate antibiotic treatment andpreventive strategies. Specific recommendations for HIV-infected children are provided.

    Validation. These guidelines are based on the available evidencesupplemented by the consensus opinion of South Africanexperts in paediatrics, paediatric pulmonology, radiology,infectious diseases and microbiology. Published internationalguidelines have also been consulted.

    S Afr Med J2005; 95:

    CLINICAL GUIDELINE

    977

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    GUIDELINE

    The papers were based on the best available published

    evidence; in the absence of evidence, expert opinion wasaccepted. Each position paper underwent a process of peerreview and revision. The position papers were synthesised intothis overall guideline, which was peer-reviewed and revisedaccordingly.

    This guideline comprises a summary document for thediagnosis and treatment of children with CAP that can bewidely implemented. A second, more detailed, comprehensivedocument comprising the separate position papers on whichthe recommendations are based will be publishedindependently. Regular review of the literature and updatingof the guideline is foreseen.

    3. Definition of CAP

    CAP can be defined as acute infection (of less than 14 daysduration), acquired in the community, of the lower respiratorytract leading to cough or difficult breathing, tachypnoea orchest-wall indrawing.

    4. Epidemiology of CAP

    CAP is a major cause of health care utilisation, hospitalisationand death in children in developing countries including SouthAfrica.1,3, 6,7 This has been exacerbated by the HIV epidemic,which has increased the incidence, severity and case fatalityfrom childhood pneumonia.3,7 CAP accounts for between 30%and 40% of hospital admissions, with associated case fatalityrates of between 15% and 28%.7,8 Risk factors for CAP areshown in Table I.

    5. Aetiology of CAP in children

    Rational treatment for pneumonia depends on knowing themost likely pathogens in each community, as the relativefrequency of different agents may vary from one geographicalregion to another. However, identifying the causal pathogen,particularly bacteria, in children with lowe

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