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CAP is the most common serious childhood infection in the u.s. CAP is associated with 3 million outpatient visits each year and >150,000 hospitalizations each year. The PIDS / IDSA national guidelines were developed by the nih/ahrq.
CAP is the most common serious childhood infection in the u.s. CAP is associated with 3 million outpatient visits each year and >150,000 hospitalizations each year. The PIDS / IDSA national guidelines were developed by the nih/ahrq.
CAP is the most common serious childhood infection in the u.s. CAP is associated with 3 million outpatient visits each year and >150,000 hospitalizations each year. The PIDS / IDSA national guidelines were developed by the nih/ahrq.
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 TM Prepared for your next patient. TM 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 presenters 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. TM 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: o National Institute of Allergy and Infectious Diseases o Agency for Healthcare Research and Quality o Childrens Hospitals Association o Robert Wood Johnson Foundation
TM 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. TM Why Do We Need Guidelines? Role of guidelines o Assist in healthcare decision-making o Reduce variation in clinical practice o 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 TM Context for the US Guidelines CAP is the most common serious childhood infection in the US. o 3 million outpatient visits each year o >150,000 hospitalizations each year o 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. Kronman MP. Pediatrics. 2011; Shah SS. J Hosp Med. 2011; Lee GE. Pediatrics. 2010; Shah SS. Pediatr Pulmonol. 2010 TM Diagnostic Testing for CAP at 43 US Hospitals Brogan TV. Pediatr Infect Dis J. 2012 TM Diagnostic Testing for CAP at 43 US Hospitals TM Diagnostic Testing for CAP at 43 US Hospitals TM Treatment for CAP at 43 US Hospitals Data from Ambroggio LV, et al. Pediatr Infect Dis J. 2012 TM
TM Available Free Online and In Print Guidelines available at: www.idsociety.org 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:e25e76 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 TM Consensus Development Based on Evidence 92 recommendations Consensus development based on evidence o GRADE working group (Grading of Recommendations, Assessment, Development, and Evaluation) o 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) TM Evidence-Based Guidelines Clinical Recommendations o Site of care o Diagnostic testing o Anti-infective treatment o Adjunctive treatment o Management of the child not responding to treatment o Discharge criteria o Prevention Future research TM Evidence-Based Guidelines Clinical Recommendations o Site of care o Diagnostic testing o Anti-infective treatment o Adjunctive treatment o Management of the child not responding to treatment o Discharge criteria o Prevention Future research TM 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 TM 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 TM Diagnostic TestingPulse 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 TM Initial Chest X-RayRecommendation
Outpatient Inpatient Recommendation NOT Recommended 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 Strong Strong Evidence Quality High Moderate Moderate TM Initial Chest X-RayRationale Chest x-rays (CXRs) not routinely required for outpatient CAP CXRs: o Do not reliably distinguish bacterial from viral CAP or among the various bacterial pathogens o Impractical in office setting Often requires travel to a separate facility Barriers to physicians obtaining timely results o CXR in outpatient setting infrequently changes clinical management Guideline provides guidance on when to perform CXR in outpatient setting 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 TM Repeat Chest X-RayRecommendation Outpatient AND Inpatient Recommendation NOT Recommended Comments
Not routinely indicated in children who recover uneventfully Recommendation Strength Strong Evidence Quality Moderate TM Repeat Chest X-RayRecommendation
Outpatient AND Inpatient Recommendation Recommended Recommended Recommended Comments
For inadequate clinical improvement, progressive symptoms, or clinical deterioration within 4872 hours after initiation of antibiotics
In children with complicated pneumonia with worsening respiratory distress or clinical instability
46 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 Strong Strong Evidence Quality Moderate Low Moderate TM Repeat Chest X-RayRationale Repeat CXRs commonly identify persistent or residual abnormalities 36 weeks later. o Abnormalities rarely alter management. o Abnormalities do not predict treatment failure or worse clinical outcome. Repeat CXRs represent unnecessary radiation exposure to infants and children. 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 TM Blood CulturesRecommendations
Outpatient Inpatient Recommendation NOT Recommended 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 Strong Strong Evidence Quality Moderate Moderate Low TM Blood CulturesRationale Outpatient o Infrequently identifies pathogens (<2%) o False-positives more common than true positives at some hospitals o Rarely informs outpatient management 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 TM Blood CulturesRationale Outpatient o Infrequently identifies pathogens (<2%) o False-positives more common than true positives at some hospitals o Rarely informs outpatient management Inpatient o Positive in ~3% of uncomplicated pneumonia o Positive in ~15% with empyema o Allows for culture-directed therapy when positive o Provides local epidemiologic data 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 TM Atypical Bacteria TestingRecommendation
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 TM Atypical Bacteria TestingRationale Evolving understanding of M. pneumoniae epidemiology o Increasingly identified in younger children
Rapid tests (IgM and PCR) available o Variable test accuracy o Treatment is not mandatory, especially with low likelihood of infection (e.g., negative test), as benefit of macrolide antibiotics uncertain Heiskanen-Kosma T. Pediatr Infect Dis J. 1998; Michelow IC. Pediatrics. 2004; Korppi M. Respirology. 2004; Thurman KA. Clin Infect Dis. 2009 TM Viral TestingRecommendations
Influenza Other Respiratory Viruses Recommendation Recommended 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 TM Diagnostic TestingViral 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 TM Viral TestingRationale Influenza testing o Positive tests reduce antibiotic use and ancillary testing (e.g., CXR, CBC) by >50%. o Positive tests guide antiviral treatment decisions. Early treatment improves outcomes. Bonner AB. Pediatrics. 2003; Esposito S. Arch Dis Child. 2003; Iyer SB. Acad Emerg Med. 2006; Benito-Fernandez J. Pediatr Infect Dis J. 2006 TM Viral TestingRecommendations
Influenza Other Respiratory Viruses Recommendation Recommended 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 TM Complete Blood CountRecommendation
Outpatient Inpatient Recommendation NOT Recommended 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 Weak Evidence Quality Low Low TM Complete Blood CountRationale Anemia and thrombocytopenia may suggest hemolytic-uremic syndrome. o Rarely an occult process. WBC count has poor specificity for diagnosis of bacterial pneumonia. o WBC elevated in many children with CAP. o Most children with elevated WBC do not have CAP. o WBC does not reliably distinguish bacterial from viral CAP. Waters AM. J Pediatr. 2007; Banerjee R. Pediatr Infect Dis J. 2011; Korppi M. Eur Respir J. 1997 TM Antibiotic ChoiceOutpatient Age of Child Infant / Preschool-Age School-Age Recommendation No antibiotics Amoxicillin 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 Strong Strong Weak Evidence Quality High Moderate Moderate Moderate TM Antibiotic ChoiceOutpatient Alternatives Allergy Amoxicillin Azithromycin Alternatives
Doxycycline (>7 years old) Levofloxacin or Moxifloxacin
TM Antibiotic ChoiceInpatient
First Line Second Line Recommendation 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. Strength Strong Weak Evidence Quality Moderate Weak TM Antibiotic ChoiceInpatient 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. Recommendation Strength Weak Strong Evidence Quality Moderate Low TM Antibiotic ChoiceRationale S. pneumoniae remains most common bacterial cause of CAP Decreasing S. pneumoniae antibiotic resistance o >50% decrease in penicillin-non-susceptible infections o >50% decrease strains in resistance to multiple antibiotics Kyaw MH. N Engl J Med. 2006 TM Antibiotic ChoiceRationale Penicillin resistance is not associated with treatment failure for non-CNS S. pneumoniae infections. o In vitro, bactericidal activity achieved at low concentrations relative to MIC o 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 Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Perez-Trallero E. J Chemother. 2001 TM Antibiotic ChoiceRationale Macrolide resistance and 2nd generation cephalosporin resistance are associated with treatment failure for non-CNS S. pneumoniae infections. Vancomycin o Not necessary for S. pneumoniae o MRSA less common and rarely occult o Challenges Poor lung penetration compared with aminopenicillins Associated with nephrotoxicity May require monitoring trough concentrations or continuous infusion Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Chung J. Anaesth Intensive Care. 2011 TM Minimizing ResistanceDuration 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. Strong recommendation; Moderate-quality evidence TM Final Thoughts Guidelines are only as good as the evidence on which they are based. TM Final Thoughts Developing guidelines is relatively easy compared to implementing them. TM Outpatient Bottom Line Test Should I do it? Comment Pulse oximetry Yes CXR No Consider in some circumstances Repeat CXR No Consider in some circumstances Influenza testing Yes During influenza season Mycoplasma Yes Encouraged if considering macrolide Sputum No Blood culture No Yes, if deterioration or no improvement CBC No TM Outpatient Bottom Line Role Antibiotic Comment First-Line Amoxicillin Alternate 2 nd /3 rd generation cephalosporin; clindamycin; levofloxacin Alternate Macrolide Add to include coverage for atypicals. Alternate Macrolide Substitute to include coverage for atypicals if pneumococcal coverage is not desired. TM Inpatient Bottom Line Test Should I do it? Comment Pulse oximetry Yes CXR Yes Repeat CXR No Consider in some circumstances Influenza testing Yes During influenza season Mycoplasma Yes Encouraged if considering macrolide Sputum Yes If child can provide Blood culture Yes CBC No TM Inpatient Bottom Line Role Antibiotic Comment First-Line Ampicillin Alternate Cefotaxime or Ceftriaxone If unimmunized Alternate Macrolide Add to include coverage for atypicals. Alternate Macrolide Substitute to include coverage for atypicals if pneumococcal coverage is not desired. TM Thank You! TM For more information On this topic and a host of other topics, visit www.pediatriccareonline.org. Pediatric Care Online is a convenient electronic resource for immediate expert help with virtually every pediatric clinical information need. Must- have resources are included in a comprehensive reference library and time-saving clinical tools.
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