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a
Infectologa Peditrica e Inmunodeficiencias, Unidad de Gestin Clnica de Pediatra, Hospital Materno-Infantil, Hospital
Regional Universitario de Mlaga, Grupo de Investigacin IBIMA, Departamento de Pediatra y Farmacologa, Facultad de
Medicina, Universidad de Mlaga, Mlaga, Spain
b
Seccin de Neumologa Peditrica, Servicio de Pediatra, Hospital Universitario Virgen Macarena, Departamento de
Farmacologa, Pediatra y Radiologa, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
c
Servicio de Pediatra, Hospital Infanta Sofa, San Sebastin de los Reyes, Madrid, Spain
d
Unidad de Neumologa Peditrica y Fibrosis Qustica, Servicio de Pediatra, Hospital Clnico Universitario, Universitat de
Valncia, Valencia, Spain
e
Unidad de Neumologa y Alergia Peditrica, Servicio de Pediatra, Hospital Universitario Son Espases, Palma de Mallorca, Islas
Baleares, Spain
f
Servicio de Pediatra, Hospital San Joan de Du, Universitat de Barcelona, Barcelona, Spain
g ebron, Barcelona, Universitat Autnoma de
Seccin de Neumologa Peditrica y Fibrosis Qustica, Hospital Universitario Vall dH
Barcelona, Barcelona, Spain
h
Unidad de Enfermedades Infecciosas e Inmunologa Clnica, Servicio de Pediatra, Hospital Universitario Germans Trias i Pujol,
Badalona, Universitat Autnoma de Barcelona, Barcelona, Spain
i
Servicio de Pediatra, Hospital 12 de Octubre, Departamento de Pediatra, Facultad de Medicina, Universidad Complutense de
Madrid, Madrid, Spain
j
Unidad de Infectologa Peditrica, Servicio de Pediatra, Hospital General Universitario Gregorio Marann, Madrid, Spain
KEYWORDS Abstract There have been significant changes in community acquired pneumonia (CAP) in chil-
Community acquired dren in the last decade. These changes are related to epidemiology and clinical presentation.
pneumonia; Resistance to antibiotics is also a changing issue. These all have to be considered when treating
Please cite this article as: Moreno-Prez D, Martn AA, Garca AT, Montaner AE, Mulet JF, Garca JJG, et al. Neumona adquirida en la
Community acquired pneumonia (CAP). In this document, two of the main Spanish pediatric
Children; societies involved in the treatment of CAP in children, propose a consensus concerning ther-
Treatment; apeutic approach. These societies are the Spanish Society of Paediatric Infectious Diseases
Prevention; and the Spanish Society of Paediatric Chest Diseases. The Advisory Committee on Vaccines of
Streptococcus the Spanish Association of Paediatrics (CAV-AEP) has also been involved in the prevention of
pneumoniae; CAP. An attempt is made to provide up-to-date guidelines to all paediatricians. The first part
Resistances; of the statement presents the approach to ambulatory, previously healthy children. We also
Vaccines review the prevention with currently available vaccines. In a second part, special situations
and complicated forms will be addressed.
2014 Asociacin Espa nola de Pediatra. Published by Elsevier Espaa, S.L.U. All rights
reserved.
Current status of resistances to antimicrobial all strains circulating in Spain are sensitive to oral amox-
drugs icillin and intravenous penicillin and ampicillin, and also
cefuroxime, if we wish to broaden the spectrum. They are all
Drug-resistant bacteria that can potentially cause CAP sensitive to cephotaxime. In recent years, the percentage of
include S. pneumoniae, S. aureus, Streptococcus pyogenes penicillin-resistant strains (intermediate sensitivity or total
(S. pyogenes) and H. influenzae type b. In Spain, other causal resistance) have risen from 60.0% to 22.9%. The proportion
agents of CAP, such as Mycoplasma pneumoniae (M. pneu- of strains with total resistance to oral penicillin (MIC 2) has
moniae) or Chlamydophila pneumoniae (C. pneumoniae), or decreased drastically from 36.5% to 0.9%. Also, 0% presents
viruses, are not drug-resistant. M. pneumoniae and C. pneu- total resistance (MIC 8) for parenteral penicillin and only
moniae are usually sensitive to macrolides and the only virus 0.2% intermediate sensitivity (MIC 4). There are still high
to be treated with antiviral drugs, the flu virus, so far does rates of resistance to macrolides (21---25%).
not present resistance to oseltamivir in our area. For H. influenzae, 15.7% are producers of -lactamases
The most reliable data on the drug-resistance of the and, therefore, resistant to penicillin, ampicillin or amox-
main respiratory pathogens in our area are periodically pro- icillin. This percentage has decreased, from the previous
vided by the multi-centre study known as Sensitivity to level of 25.7%.
Antibiotic Drugs Used in the Community in Spain (SAUCE These data, based on samples from children and adults
in Spanish). The latest, published in 2010 as the SAUCE-4 taken 6---7 years ago, can be combined with the findings of a
study,8 offers results on sensitivity and resistance according recent study by Heracles in the Community of Madrid (May
to official cutoff points (CLSI cutoff points). It contains a 2011---April 2013),9,10 where 100% of S. pneumoniae strains
total of 2559 isolations of S. pneumoniae, 2287 of S. pyo- isolated in children under 15 years old with invasive pneumo-
genes and 2287 of H. influenzae, and these are compared cocci disease outside the central nervous system----including
to those recorded in the previous 11 years. In summary, the bacteraemia pneumonias and empyema----are sensitive to
most relevant data are described in Table 1. For S. pneumo- penicillin and cephotaxime.
niae, as regards sensitivity to -lactams, currently almost
Adjuvant support treatment
Table 1 Sensitivity of the main bacteria causing CAP in
Spain (data from the SAUCE-4 study). In children with CAP, antibiotic therapy at times needs to be
complemented with other strategies, although this is less
Bacteria Type of Percentage pf frequent in patients not requiring hospitalisation.
antibiotics sensitive strains Children with pneumonia usually feel associated pain
Streptococcus -Lactams Amoxicillin (at (pleuritic, abdominal, headache) and discomfort or pain
pneumoniae, in high doses): 98.8% due to inflammation of upper airways (otalgia, odynopha-
infections outside gia). Analgesia is recommended for relief, especially
the central nervous in cases of pleuritic pain, because it interferes with
system coughing and breathing.11,12 Paracetamol can be used
Ampicillin: 93.4% (15 mg/kg/6 h; up to a maximum of 75 mg/kg/day) or ibupro-
Parenteral fen (5---10 mg/kg/6---8 h). Fever must be controlled with
penicillin: 99.8% these same agents, as oxygen requirements increase. There
Cephotaxime: is insufficient evidence that mucolytic and cough suppres-
99.6% sants are beneficial, and in theory, medications with codeine
Oral cefuroxime: or antihistamines should not be used in young children.13
94.5% Increased effort of breathing and fever increase the
Parenteral requirement for fluids. The ideal way to provide them is
cefuroxime: 99.3% orally, in small amounts and frequently.
Macrolides Erythromycin,
clarithromycin,
azithromycin: Ambulatory treatment of non-complicated
75---79% CAP with antibiotics
Quinolones Levofloxacin:
97.7% Indication for the use of antibiotics
Haemophilus -Lactams Amoxicillin,
influenzae ampicillin, Empirical treatment of CAP is based on the pathogens
penicillin: 85% most frequently involved. However, one of the most impor-
Macrolides 100% tant problems is correct distinction between probable viral
Streptococcus -lactams 100% aetiology and probable bacterial aetiology. Clinicians tend,
pyogenes mistakenly, to use antibiotics in excess, which leads to an
Macrolides Erythromycin, increase in antimicrobial resistances. In patients aged less
clarithromycin, than 2 years, with mild clinical lower airway manifesta-
azithromycin: 65% tions and a history of correct immunisation according to age
Adapted from Prez-Trallero et al.8
against H. influenzae type b and S. pneumoniae bacterial
aetiology is unlikely.14
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Antibiotics are indicated in typical CAP where bacterial --- Children with respiratory infections frequently vomit,
aetiology is suspected. In cases of atypical CAP they should which may cause infradosage scenarios, especially if low
only be used in children over 4---5 years old and in certain doses are used.
younger patients if the infection is serious. --- In pneumococcal infections of the upper airways (acute
For treatment under special circumstances (allergy to - otitis media and sinusitis), it is necessary to continue to
lactams, base disease, immunodepressed, etc.), or patients use high doses due to lower penetration of drugs in these
requiring hospitalisation, more information will be available locations. It is preferable to harmonise the dosage of this
in the specific document that will be published in a subse- oral antibiotic for all pneumococcal infections, for the
quent issue of this journal. purpose of minimising prescription errors.
Preventive measures. Vaccines has been reported, and a 70% reduction in cases attributed
to PCV13, while hospitalisation for CAP in children under 2
Vaccination against certain microorganisms has proven to years of age fell by 65% in 2012.30,27
have an impact on the incidence and mortality of CAP world- In Latin America, several countries have published good
wide. The aetiological agents for which there are vaccines results after the introduction of PCV13 in their vaccination
available are S. pneumoniae, H. influenzae type b and the calendars, including Argentina, with a 41% reduction in cases
flu virus. of CAP in children under 5 years old.31 In Uruguay, hospi-
talisation for CAP in the under-14 age group has decreased
by 78% overall, and by 92% in cases of pneumococcal
Vaccination against S. pneumoniae origin.32