Pneumonia- clinical guidelines

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Clinical Practice Guidelines

In theEvaluation and MANAGEMENTOf PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA



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QUICK GUIDE: OBJECTIVE



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What diagnostic aidsare initially requestedfor a patient classified

as either PCAP A or PCAP B beingmanaged in an

ambulatory setting?



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What diagnostic

aids are initiallyrequested for apatient classified

as either PCAP Cor PCAP D beingmanaged in ahospital setting?



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Key Recommendation

1. The following should be routinely requested:a. Chest x-ray PA-lateral

b. White blood Cell Count

c. Culture and Sensitivity of i. Blood for PCAP D

ii. Pleural fluid (thoracentesis for pleural effusion)

iii. Tracheal aspirate upon initialintubation

d. Blood gas and/or pulse oximetry (assess gas

exchange)



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Key Recommendation

2. The following may be requested:

* Culture and Sensitivity of sputum for

Older children3. The following should not be routinelyrequested: (not shown to demonstrate viral from bacterial

infection)

a. Erythrocyte sedimentation rate

b. C- reactive protein



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QUICK GUIDE: OBJECTIVE



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When is ANTIBIOTICRECOMMENDED?



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KEY RECOMMENDATION

1. For a patient classified as either PCAP Aor PCAP B and is

a. beyond 2 years of age ; OR

B. having high grade fever withoutwheeze



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rationale

Microbial etiology:

* ≤ 2 y.o.- VIRUSES are most frequentlyimplicated.

As age increases, Bacterial pathogens

(Streptococcus pneumoniae, Mycoplasma

sp and Chlamydia sp) become moreprevalent.



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rationale

FEATURES BACTERIAL VIRAL

Fever T°= > 38.5 °C T°= < 38.5 °C

Wheeze Absent Present



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KEY RECOMMENDATION

2. For a patient classified as PCAP C and is

a. beyond 2 years of age; OR

b. having OR high grade fever withoutwheeze

c. having alveolar consolidation in thechest x-ray; OR

d. having white blood cell count >15000

3. For a patient classified as PCAP D



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What empiric treatment

should be administered if abacterial etiology isSTRONGLY considered?



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Key recommendation

1. For a patient classified asPCAP A or B without

previous antibiotic:

DOC: ORAL AMOXICILLIN 40-50mg/kg/day in 3 divided doses

Alternative: Co-trimoxazole andChloramphenicol palmitate



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Oral Amoxicillin

a. Failure rate higher in Co-trimoxazolecompared to Amoxicillin.

b. Failure rate was lower in the Amoxicillingroup compared with chloramphenicol

Amoxicillin vs Azithromycin

Improvement in CXR is greater than 75% in the Azithromycin group vs Amoxicillin

Amoxicillin vs ErythromycinNo difference between amoxicillin and

erythromycin as to cure rate.



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2. For a patient classified as PCAP C withoutprevious antibiotic and who has completed

the primary immunization againstHaemophilus influenzae type B

DOC: Penicillin G (100,000 U/kg/day) in 4

divided doses

If a primary immunization against H ib has

NOT been completed:DOC: Ampicillin IV (100 mg/kg/day) in 4divided doses should be given



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3. For apatient

classified asPCAP D, aspecialist

should beconsulted.



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2008 Update Highlights:Epedemiology

CAP Common Pathogens:* Streptococcus pneumoniae

*Mycoplasma pneumoniae

*Chlamydia pneumoniae

Pathogen

CA- MRSA (Community Acquired Methicillin

Resistant Staphylococcus aureus

* 93% of MRSA were CA-MRSA

* Hospital Rate MRSA 31%



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Antibiotic Resistance (Local Data)

Penicillin ChloramphenicolAmpicillin Co-trimoxazole

S. pneumoniae 6% 5% No data 14%

H. influenzae No data 14% 9% 15%

CA-MRSA- DOC: Vancomycin



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Update highlights

For PCAP A and B* There is evidence for the use of Amoxicilin

(45mg/kg/day), 3 divided doses for a minimumduration of 3 days)

* Among patients with known hypersensitivity toamoxicillin, a MACROLIDE antibiotic may beconsidered

* Use of Co-trimoxazole is discouraged because of high failure and resistance rates.



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Update highlights

For PCAP C

* Equal efficacies were noted between Oralamoxicillin and Parenteral Penicillin among

patients who can tolerate feeding.*Equal efficacies were noted between

monotherapy and Combination therapy for thosewho cannot tolerate feeding.

* For monotherapy --- Parenteral Ampicillin is

the best choice considering the cost.



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What treatmentshould be initiallygiven if a VIRALetiology isstrongly

considered



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Key recommendation

1. Ancillary treatment should only begiven.

2. OSELTAMIVIR (2 mg/kg/dose BID for 5days) or AMANTADINE (4.4- 8.8mg/kg/day for 3-5 days) may be given for influenza that is either confirmed bylaboratory or occurring as an outbreak..



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Ancillary Treatments

1. Among inpatients, OXYGEN andHYDRATION should be given if needed.

2. Cough preparations, chest physiotherapy,

bronchial hygiene, nebulization usingNormal Saline Solution, steam inhalation,topical solution, brochodilators and herbalmedicines are not routinely given in

community-acquired pneumonia3. In the presence of WHEEZING, a

bronchodilator may be administered.



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When can apatient be

considered asresponding tothe currentantibiotic



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1. Favorable response: Decrease inRESPIRATORY SIGNS (Tachypnea) and

defervescence within 72 hours after initiationof antibiotic.

2. Reevaluate: Persistence of symptomsbeyond 72 hours after initiation of antibiotics.

3. End of treatment Chest x-ray, WBC, ESR,or CRP should not be done to assesstherapeutic response to antibiotic.



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What should be

done if a patientis NOTresponding tocurrent antibiotictherapy?



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Key recommendation

1. If an outpatient classified as either PCAP A or PCAP B is not responding to the currentantibiotic within 72 hours, consider any one of the following:

a. Change the initial antibiotic (Amoxicillin) to:Cefuroxime axetil, Co-Amoxiclav, Sultamicillin,or Cefpodoxime.

b. Start and Oral Macrolide (Mycoplasma/Chlamydia)

c. Reevaluate Diagnosis



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Cefuroxime axetil 20-30 mg/kg/day BID x 7days

Co- Amoxiclav 40-50 mg of Amoxicillin/kg/day

BIB x 7 daysSultamicillin 25-50 mg/kg/day, TID/QID x 7days

Cefpodoxime proxetil 20mg/kg/day BID x 7days



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3. If an inpatient as PCAP D isnot responding to the current

antibiotic within 72 hours,consider immediate RE-CONSULTATION with a

specialist.



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Key recommendation

2. If an inpatient classified as PCAP C is notresponding to the current antibiotic within72 hour, consider consultation with aspecialist because of the followingpossibilities:

a. Penicillin resistant Streptococcuspneumoniae; or

b. presence of complications (pulmonary or extrapulmonary);

c. other diagnosis



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When canSwitch

therapy in

bacterialpneumonia be

started?



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Switch from Intravenous antibiotic

administration to oral form 2-3 days after initiation of antibiotic is recommended in apatient who

a. is responding to the initial antibiotictherapy.

b. is able to feed with intact

gastrointestinal absorption; andc. does not have any pulmonary or

extrapulmonary complications..



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How can

Pneumonia beprevented?



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1. Vaccines recommended by the Philippine

Pediatric Society should be routinelyadministered to prevent pneumonia.

2. Zinc Supplementation (10 mg for infants

and 20 mg for children >20 years of agegiven for a total of 4 – 6 months) may beadministered to prevent pneumonia.

3. Vitamin A, immunomodulators and vitaminC should not be routinely administered as apreventive strategy.



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References

1. CPG (Clinical Practice Guidelines In TheEvaluation and Management of PediatricCommunity Acquired Pneumonia)

2. Nelson Textbook of Pediatrics



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Pneumonia- clinical guidelines