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2011 cap in children

  1. 1. Clinical Infectious Diseases Advance Access published August 30, 2011 31, IDSA GUIDELINESThe Management of Community-AcquiredPneumonia in Infants and Children Older Than3 Months of Age: Clinical Practice Guidelines bythe Pediatric Infectious Diseases Society and theInfectious Diseases Society of AmericaJohn S. Bradley,1,a Carrie L. Byington,2,a Samir S. Shah,3,a Brian Alverson,4 Edward R. Carter,5 Christopher Harrison,6Sheldon L. Kaplan,7 Sharon E. Mace,8 George H. McCracken Jr,9 Matthew R. Moore,10 Shawn D. St Peter,11Jana A. Stockwell,12 and Jack T. Swanson131Department of Pediatrics, University of California San Diego School of Medicine and Rady Childrens Hospital of San Diego, San Diego, California;2Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; 3Departments of Pediatrics, and Biostatistics and Epidemiology,University of Pennsylvania School of Medicine, and Division of Infectious Diseases, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania;4Department of Pediatrics, Rhode Island Hospital, Providence, Rhode Island; 5Pulmonary Division, Seattle Childrens Hospital, Seattle Washington; Downloaded from cid.oxfordjournals.org at IDSA on August 31, 20116Department of Pediatrics, Childrens Mercy Hospital, Kansas City, Missouri; 7Department of Pediatrics, Baylor College of Medicine, Houston, Texas;8Department of Emergency Medicine, Cleveland Clinic, Cleveland, Ohio; 9Department of Pediatrics, University of Texas Southwestern, Dallas, Texas;10Centers for Disease Control and Prevention, Atlanta, Georgia; 11Department of Pediatrics, University of Missouri–Kansas City School of Medicine,Kansas City, Missouri; 12Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and 13Department of Pediatrics, McFarlandClinic, Ames, IowaEvidenced-based guidelines for management of infants and children with community-acquired pneumonia(CAP) were prepared by an expert panel comprising clinicians and investigators representing communitypediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine,infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care andsubspecialty providers responsible for the management of otherwise healthy infants and children with CAP inboth outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctivesurgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.EXECUTIVE SUMMARY of a child with CAP. They do not represent the only approach to diagnosis and therapy; there is considerableGuidelines for the management of community-acquired variation among children in the clinical course of pe-pneumonia (CAP) in adults have been demonstrated to diatric CAP, even with infection caused by the samedecrease morbidity and mortality rates [1, 2]. These pathogen. The goal of these guidelines is to decreaseguidelines were created to assist the clinician in the care morbidity and mortality rates for CAP in children by presenting recommendations for clinical management that can be applied in individual cases if deemed ap- propriate by the treating clinician. Received 1 July 2011; accepted 8 July 2011. a J. S. B., C. L. B., and S. S. S. contributed equally to this work. This document is designed to provide guidance in the Correspondence: John S. Bradley, MD, Rady Childrens Hospital San Diego/ care of otherwise healthy infants and children and ad-UCSD, 3020 Childrens Way, MC 5041, San Diego, CA 92123 (jbradley@rchsd.org). dresses practical questions of diagnosis and managementClinical Infectious DiseasesÓ The Author 2011. Published by Oxford University Press on behalf of the Infectious of CAP evaluated in outpatient (offices, urgent careDiseases Society of America. All rights reserved. For Permissions, please e-mail: clinics, emergency departments) or inpatient settings injournals.permissions@oup.com.1058-4838/2011/537-0024$14.00 the United States. Management of neonates and youngDOI: 10.1093/cid/cir531 infants through the first 3 months, immunocompromised Pediatric Community Pneumonia Guidelines d CID d e1
  2. 2. children, children receiving home mechanical ventilation, and 7. A child should be admitted to an ICU or a unit withchildren with chronic conditions or underlying lung disease, such continuous cardiorespiratory monitoring capabilities if the childas cystic fibrosis, are beyond the scope of these guidelines and are has impending respiratory failure. (strong recommendation;not discussed. moderate-quality evidence) Summarized below are the recommendations made in the new 8. A child should be admitted to an ICU or a unit with2011 pediatric CAP guidelines. The panel followed a process used continuous cardiorespiratory monitoring capabilities if the childin the development of other Infectious Diseases Society of has sustained tachycardia, inadequate blood pressure, or need forAmerica (IDSA) guidelines, which included a systematic weight- pharmacologic support of blood pressure or perfusion. (stronging of the quality of the evidence and the grade of the recom- recommendation; moderate-quality evidence)mendation [3] (Table 1). A detailed description of the methods, 9. A child should be admitted to an ICU if the pulsebackground, and evidence summaries that support each of the oximetry measurement is ,92% on inspired oxygen of $0.50.recommendations can be found in the full text of the guidelines. (strong recommendation; low-quality evidence) 10. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if theSITE-OF-CARE MANAGEMENT DECISIONS child has altered mental status, whether due to hypercarbia or hypoxemia as a result of pneumonia. (strong recommendation;I. When Does a Child or Infant With CAP Require Hospitalization? low-quality evidence)Recommendations 11. Severity of illness scores should not be used as the sole 1. Children and infants who have moderate to severe CAP, criteria for ICU admission but should be used in the context ofas defined by several factors, including respiratory distress and other clinical, laboratory, and radiologic findings. (stronghypoxemia (sustained saturation of peripheral oxygen [SpO2], recommendation; low-quality evidence),90 % at sea level) (Table 3) should be hospitalized for Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011management, including skilled pediatric nursing care. (strong DIAGNOSTIC TESTING FOR PEDIATRIC CAPrecommendation; high-quality evidence) 2. Infants less than 3–6 months of age with suspected III. What Diagnostic Laboratory and Imaging Tests Should Bebacterial CAP are likely to benefit from hospitalization. (strong Used in a Child With Suspected CAP in an Outpatient orrecommendation; low-quality evidence) Inpatient Setting? 3. Children and infants with suspected or documented RecommendationsCAP caused by a pathogen with increased virulence, such as Microbiologic Testingcommunity-associated methicillin-resistant Staphylococcus aureus Blood Cultures: Outpatient(CA-MRSA) should be hospitalized. (strong recommendation; low-quality evidence) 12. Blood cultures should not be routinely performed in 4. Children and infants for whom there is concern about nontoxic, fully immunized children with CAP managed in thecareful observation at home or who are unable to comply with outpatient setting. (strong recommendation; moderate-qualitytherapy or unable to be followed up should be hospitalized. evidence)(strong recommendation; low-quality evidence) 13. Blood cultures should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiationII. When Should a Child With CAP Be Admitted to an Intensive of antibiotic therapy (strong recommendation; moderate-qualityCare Unit (ICU) or a Unit With Continuous Cardiorespiratory evidence).Monitoring?Recommendations Blood Cultures: Inpatient 5. A child should be admitted to an ICU if the child requires 14. Blood cultures should be obtained in children requiringinvasive ventilation via a nonpermanent artificial airway hospitalization for presumed bacterial CAP that is moderate to(eg, endotracheal tube). (strong recommendation; high-quality severe, particularly those with complicated pneumonia. (strongevidence) recommendation; low-quality evidence) 6. A child should be admitted to an ICU or a unit with 15. In improving patients who otherwise meet criteriacontinuous cardiorespiratory monitoring capabilities if the for discharge, a positive blood culture with identification orchild acutely requires use of noninvasive positive pressure susceptibility results pending should not routinely precludeventilation (eg, continuous positive airway pressure or bilevel discharge of that patient with appropriate oral or intravenouspositive airway pressure). (strong recommendation; very low- antimicrobial therapy. The patient can be discharged if closequality evidence) follow-up is assured. (weak recommendation; low-quality evidence)e2 d CID d Bradley et al
  3. 3. Table 1. Strength of Recommendations and Quality of EvidenceStrength of recommendation Clarity of balance between Methodologic quality of supportingand quality of evidence desirable and undesirable effects evidence (examples) ImplicationsStrong recommendationHigh-quality evidence Desirable effects clearly Consistent evidence from well- Recommendation can apply to outweigh undesirable effects, performed RCTsa or exceptionally most patients in most or vice versa strong evidence from unbiased circumstances; further observational studies research is unlikely to change our confidence in the estimate of effect.Moderate-quality evidence Desirable effects clearly Evidence from RCTs with important Recommendation can apply to outweigh undesirable effects, limitations (inconsistent results, most patients in most or vice versa methodologic flaws, indirect, or circumstances; further imprecise) or exceptionally strong research (if performed) is evidence from unbiased likely to have an important observational studies impact on our confidence in the estimate of effect and may change the estimate.Low-quality evidence Desirable effects clearly Evidence for $1 critical outcome Recommendation may change outweigh undesirable effects, from observational studies, RCTs when higher quality evidence or vice versa with serious flaws or indirect becomes available; further evidence research (if performed) is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.Very low-quality evidence Desirable effects clearly Evidence for $1 critical outcome Recommendation may change Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011 (rarely applicable) outweigh undesirable effects, from unsystematic clinical when higher quality evidence or vice versa observations or very indirect becomes available; any evidence estimate of effect for $1 critical outcome is very uncertain.Weak recommendationHigh-quality evidence Desirable effects closely Consistent evidence from well- The best action may differ balanced with undesirable performed RCTs or exceptionally depending on circumstances effects strong evidence from unbiased or patients or societal values; observational studies further research is unlikely to change our confidence in the estimate of effect.Moderate-quality evidence Desirable effects closely Evidence from RCTs with important Alternative approaches are likely balanced with undesirable limitations (inconsistent results, to be better for some patients effects methodologic flaws, indirect, or under some circumstances; imprecise) or exceptionally strong further research (if performed) evidence from unbiased is likely to have an important observational studies impact on our confidence in the estimate of effect and may change the estimate.Low-quality evidence Uncertainty in the estimates of Evidence for $1 critical outcome Other alternatives may be equally desirable effects, harms, and from observational studies, from reasonable; further research is burden; desirable effects, RCTs with serious flaws or indirect very likely to have an important harms, and burden may be evidence impact on our confidence in the closely balanced estimate of effect and is likely to change the estimate.Very low-quality evidence Major uncertainty in estimates Evidence for $1 critical outcome from Other alternatives may be equally of desirable effects, harms, unsystematic clinical observations or reasonable; any estimate of and burden; desirable effects 2very indirect evidence effect, for at $1 critical may or may not be balanced outcome, is very uncertain. with undesirable effects may be closely balanced a RCTs, randomized controlled trials. Pediatric Community Pneumonia Guidelines d CID d e3
  4. 4. Table 2. Complications Associated With Community-Acquired Urinary Antigen Detection TestsPneumonia 19. Urinary antigen detection tests are not recommendedPulmonary for the diagnosis of pneumococcal pneumonia in children; Pleural effusion or empyema false-positive tests are common. (strong recommendation; high- Pneumothorax quality evidence) Lung abscess Testing For Viral Pathogens Bronchopleural fistula Necrotizing pneumonia 20. Sensitive and specific tests for the rapid diagnosis of Acute respiratory failure influenza virus and other respiratory viruses should be used inMetastatic the evaluation of children with CAP. A positive influenza test Meningitis may decrease both the need for additional diagnostic studies Central nervous system abscess and antibiotic use, while guiding appropriate use of antiviral Pericarditis agents in both outpatient and inpatient settings. (strong Endocarditis recommendation; high-quality evidence) Osteomyelitis 21. Antibacterial therapy is not necessary for children, either Septic arthritis outpatients or inpatients, with a positive test for influenza virusSystemic Systemic inflammatory response syndrome or sepsis in the absence of clinical, laboratory, or radiographic findings Hemolytic uremic syndrome that suggest bacterial coinfection. (strong recommendation; high-quality evidence). 22. Testing for respiratory viruses other than influenza virusFollow-up Blood Cultures can modify clinical decision making in children with suspected 16. Repeated blood cultures in children with clear clinical pneumonia, because antibacterial therapy will not routinely be Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011improvement are not necessary to document resolution of required for these children in the absence of clinical, laboratory,pneumococcal bacteremia. (weak recommendation; low-quality or radiographic findings that suggest bacterial coinfection.evidence) (weak recommendation; low-quality evidence) 17. Repeated blood cultures to document resolution of Testing for Atypical Bacteriabacteremia should be obtained in children with bacteremia 23. Children with signs and symptoms suspicious forcaused by S. aureus, regardless of clinical status. (strong Mycoplasma pneumoniae should be tested to help guiderecommendation; low-quality evidence) antibiotic selection. (weak recommendation; moderate-qualitySputum Gram Stain and Culture evidence) 18. Sputum samples for culture and Gram stain should be 24. Diagnostic testing for Chlamydophila pneumoniae is notobtained in hospitalized children who can produce sputum. recommended as reliable and readily available diagnostic tests(weak recommendation; low-quality evidence) do not currently exist. (strong recommendation; high-quality evidence)Table 3. Criteria for Respiratory Distress in Children With Ancillary Diagnostic TestingPneumonia Complete Blood Cell CountSigns of Respiratory Distress 25. Routine measurement of the complete blood cell count is not necessary in all children with suspected CAP managed in the1. Tachypnea, respiratory rate, breaths/mina outpatient setting, but in those with more serious disease it may Age 0–2 months: .60 Age 2–12 months: .50 provide useful information for clinical management in the Age 1–5 Years: .40 context of the clinical examination and other laboratory and Age .5 Years: .20 imaging studies. (weak recommendation; low-quality evidence)2. Dyspnea 26. A complete blood cell count should be obtained for3. Retractions (suprasternal, intercostals, or subcostal) patients with severe pneumonia, to be interpreted in the context4. Grunting of the clinical examination and other laboratory and imaging5. Nasal flaring studies. (weak recommendation; low-quality evidence)6. Apnea7. Altered mental status Acute-Phase Reactants8. Pulse oximetry measurement ,90% on room air 27. Acute-phase reactants, such as the erythrocyte sedimentation a Adapted from World Health Organization criteria. rate (ESR), C-reactive protein (CRP) concentration, or serume4 d CID d Bradley et al
  5. 5. procalcitonin concentration, cannot be used as the sole determinant Table 4. Criteria for CAP Severity of Illness in Children withto distinguish between viral and bacterial causes of CAP. (strong Community-Acquired Pneumoniarecommendation; high-quality evidence) 28. Acute-phase reactants need not be routinely Criteriameasured in fully immunized children with CAP who are Major criteriamanaged as outpatients, although for more serious disease, Invasive mechanical ventilationacute-phase reactants may provide useful information for Fluid refractory shock Acute need for NIPPVclinical management. (strong recommendation; low-quality Hypoxemia requiring FiO2 greater than inspired concentration orevidence) flow feasible in general care area 29. In patients with more serious disease, such as those Minor criteriarequiring hospitalization or those with pneumonia-associated Respiratory rate higher than WHO classification for agecomplications, acute-phase reactants may be used in Apneaconjunction with clinical findings to assess response to Increased work of breathing (eg, retractions, dyspnea, nasal flaring, grunting)therapy. (weak recommendation; low-quality evidence) PaO2/FiO2 ratio ,250Pulse Oximetry Multilobar infiltrates PEWS score .6 30. Pulse oximetry should be performed in all children with Altered mental statuspneumonia and suspected hypoxemia. The presence of Hypotensionhypoxemia should guide decisions regarding site of care and Presence of effusionfurther diagnostic testing. (strong recommendation; moderate- Comorbid conditions (eg, HgbSS, immunosuppression, immunodeficiency)quality evidence) Unexplained metabolic acidosis Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011Chest Radiography Modified from Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquiredInitial Chest Radiographs: Outpatient pneumonia in adults [27, table 4]. Clinician should consider care in an intensive care unit or a unit with continuous cardiorespiratory monitoring for the child 31. Routine chest radiographs are not necessary for the having $1 major or $2 minor criteria.confirmation of suspected CAP in patients well enough to be Abbreviations: FiO2, fraction of inspired oxygen; HgbSS, Hemoglobin SStreated in the outpatient setting (after evaluation in the disease; NIPPV, noninvasive positive pressure ventilation; PaO2, arterial oxygen pressure; PEWS, Pediatric Early Warning Score [70].office, clinic, or emergency department setting). (strongrecommendation; high-quality evidence) 32. Chest radiographs, posteroanterior and lateral, should 35. Repeated chest radiographs should be obtained inbe obtained in patients with suspected or documented children who fail to demonstrate clinical improvement andhypoxemia or significant respiratory distress (Table 3) and in in those who have progressive symptoms or clinicalthose with failed initial antibiotic therapy to verify the presence deterioration within 48–72 hours after initiation ofor absence of complications of pneumonia, including antibiotic therapy. (strong recommendation; moderate-qualityparapneumonic effusions, necrotizing pneumonia, and evidence)pneumothorax. (strong recommendation; moderate-quality 36. Routine daily chest radiography is not recommendedevidence) in children with pneumonia complicated by parapneumonic effusion after chest tube placement or after video-Initial Chest Radiographs: Inpatient assisted thoracoscopic surgery (VATS), if they remain 33. Chest radiographs (posteroanterior and lateral) should be clinically stable. (strong recommendation; low-qualityobtained in all patients hospitalized for management of CAP to evidence)document the presence, size, and character of parenchymal 37. Follow-up chest radiographs should be obtained ininfiltrates and identify complications of pneumonia that may patients with complicated pneumonia with worseninglead to interventions beyond antimicrobial agents and supportive respiratory distress or clinical instability, or in those withmedical therapy. (strong recommendation; moderate-quality persistent fever that is not responding to therapy over 48-72evidence) hours. (strong recommendation; low-quality evidence) 38. Repeated chest radiographs 4–6 weeks after theFollow-up Chest Radiograph diagnosis of CAP should be obtained in patients with 34. Repeated chest radiographs are not routinely required in recurrent pneumonia involving the same lobe and inchildren who recover uneventfully from an episode of CAP. patients with lobar collapse at initial chest radiography(strong recommendation; moderate-quality evidence) with suspicion of an anatomic anomaly, chest mass, or Pediatric Community Pneumonia Guidelines d CID d e5
  6. 6. foreign body aspiration. (strong recommendation; moderate- M. pneumoniae should be performed if available in a clinicallyquality evidence) relevant time frame. Table 5 lists preferred and alternative agents for atypical pathogens. (weak recommendation; moderate-qualityIV. What Additional Diagnostic Tests Should Be Used in a Child evidence)With Severe or Life-Threatening CAP? 45. Influenza antiviral therapy (Table 6) should beRecommendations administered as soon as possible to children with moderate to severe CAP consistent with influenza virus infection during 39. The clinician should obtain tracheal aspirates for Gram widespread local circulation of influenza viruses, particularlystain and culture, as well as clinically and epidemiologically for those with clinically worsening disease documented at theguided testing for viral pathogens, including influenza virus, at time of an outpatient visit. Because early antiviral treatment hasthe time of initial endotracheal tube placement in children been shown to provide maximal benefit, treatment should not berequiring mechanical ventilation. (strong recommendation; low- delayed until confirmation of positive influenza test results.quality evidence) Negative results of influenza diagnostic tests, especially rapid 40. Bronchoscopic or blind protected specimen brush antigen tests, do not conclusively exclude influenza disease.sampling, bronchoalveolar lavage (BAL), percutaneous lung Treatment after 48 hours of symptomatic infection may stillaspiration, or open lung biopsy should be reserved for the provide clinical benefit to those with more severe disease. (strongimmunocompetent child with severe CAP if initial diagnostic recommendation; moderate-quality evidence)tests are not positive. (weak recommendation; low-qualityevidence) Inpatients 46. Ampicillin or penicillin G should be administered to theANTI-INFECTIVE TREATMENT fully immunized infant or school-aged child admitted to Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011 a hospital ward with CAP when local epidemiologic dataV. Which Anti-Infective Therapy Should Be Provided to a Child document lack of substantial high-level penicillin resistance forWith Suspected CAP in Both Outpatient and Inpatient Settings? invasive S. pneumoniae. Other antimicrobial agents for empiricRecommendations therapy are provided in Table 7. (strong recommendation;Outpatients moderate-quality evidence) 41. Antimicrobial therapy is not routinely required for 47. Empiric therapy with a third-generation parenteralpreschool-aged children with CAP, because viral pathogens are cephalosporin (ceftriaxone or cefotaxime) should beresponsible for the great majority of clinical disease. (strong prescribed for hospitalized infants and children who arerecommendation; high-quality evidence) not fully immunized, in regions where local epidemiology of 42. Amoxicillin should be used as first-line therapy for invasive pneumococcal strains documents high-levelpreviously healthy, appropriately immunized infants and penicillin resistance, or for infants and children with life-preschool children with mild to moderate CAP suspected to threatening infection, including those with empyemabe of bacterial origin. Amoxicillin provides appropriate (Table 7). Non–b-lactam agents, such as vancomycin, havecoverage for Streptococcus pneumoniae, the most prominent not been shown to be more effective than third-generationinvasive bacterial pathogen. Table 5 lists preferred agents and cephalosporins in the treatment of pneumococcalalternative agents for children allergic to amoxicillin (strong pneumonia for the degree of resistance noted currently inrecommendation; moderate-quality evidence) North America. (weak recommendation; moderate-quality 43. Amoxicillin should be used as first-line therapy for evidence)previously healthy appropriately immunized school-aged 48. Empiric combination therapy with a macrolide (oral orchildren and adolescents with mild to moderate CAP for parenteral), in addition to a b-lactam antibiotic, should beS. pneumoniae, the most prominent invasive bacterial prescribed for the hospitalized child for whom M. pneumoniaepathogen. Atypical bacterial pathogens (eg, M. pneumoniae), and C. pneumoniae are significant considerations; diagnosticand less common lower respiratory tract bacterial pathogens, as testing should be performed if available in a clinically relevantdiscussed in the Evidence Summary, should also be considered in time frame (Table 7). (weak recommendation; moderate-qualitymanagement decisions. (strong recommendation; moderate- evidence)quality evidence) 49. Vancomycin or clindamycin (based on local susceptibility 44. Macrolide antibiotics should be prescribed for treatment data) should be provided in addition to b-lactam therapy ifof children (primarily school-aged children and adolescents) clinical, laboratory, or imaging characteristics are consistentevaluated in an outpatient setting with findings compatible with infection caused by S. aureus (Table 7). (strongwith CAP caused by atypical pathogens. Laboratory testing for recommendation; low-quality evidence)e6 d CID d Bradley et al
  7. 7. Table 5. Selection of Antimicrobial Therapy for Specific Pathogens Oral therapy (step-down therapyPathogen Parenteral therapy or mild infection)Streptococcus pneumoniae with Preferred: ampicillin (150–200 mg/kg/day every Preferred: amoxicillin (90 mg/kg/day in MICs for penicillin #2.0 lg/mL 6 hours) or penicillin (200 000–250 000 U/kg/day 2 doses or 45 mg/kg/day in 3 doses); every 4–6 h); Alternatives: second- or third-generation Alternatives: ceftriaxone cephalosporin (cefpodoxime, cefuroxime, (50–100 mg/kg/day every 12–24 hours) (preferred cefprozil); oral levofloxacin, if susceptible for parenteral outpatient therapy) or cefotaxime (16–20 mg/kg/day in 2 doses for children (150 mg/kg/day every 8 hours); may also be 6 months to 5 years old and 8–10 mg/kg/day effective: clindamycin (40 mg/kg/day every once daily for children 5 to 16 years old; 6–8 hours) or vancomycin (40–60 mg/kg/day every maximum daily dose, 750 mg) or oral 6–8 hours) linezolid (30 mg/kg/day in 3 doses for children ,12 years old and 20 mg/kg/day in 2 doses for children $12 years old)S. pneumoniae resistant to Preferred: ceftriaxone (100 mg/kg/day every Preferred: oral levofloxacin (16–20 mg/kg/day penicillin, with MICs 12–24 hours); in 2 doses for children 6 months to 5 years $4.0 lg/mL and 8–10 mg/kg/day once daily for children Alternatives: ampicillin 5–16 years, maximum daily dose, 750 mg), (300–400 mg/kg/day every 6 hours), levofloxacin if susceptible, or oral linezolid (30 mg/kg/day (16–20 mg/kg/day every 12 hours for children in 3 doses for children ,12 years and 6 months to 5 years old and 8–10 mg/kg/day 20 mg/kg/day in 2 doses for children once daily for children 5–16 years old; maximum $12 years); daily dose, 750 mg), or linezolid (30 mg/kg/day every 8 hours for children ,12 years old and Alternative: oral clindamycina 20 mg/kg/day every 12 hours for children $12 years (30–40 mg/kg/day in 3 doses) old); may also be effective: clindamycina Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011 (40 mg/kg/day every 6–8 hours) or vancomycin (40–60 mg/kg/day every 6–8 hours)Group A Streptococcus Preferred: intravenous penicillin (100 000–250 000 Preferred: amoxicillin (50–75 mg/kg/day in U/kg/day every 4–6 hours) or ampicillin 2 doses), or penicillin V (50–75 mg/kg/day in (200 mg/kg/day every 6 hours); 3 or 4 doses); Alternatives: ceftriaxone (50–100 mg/kg/day every Alternative: oral clindamycina 12–24 hours) or cefotaxime (150 mg/kg/day every (40 mg/kg/day in 3 doses) 8 hours); may also be effective: clindamycin, if susceptible (40 mg/kg/day every 6–8 hours) or vancomycinb (40–60 mg/kg/day every 6–8 hours)Stapyhylococcus aureus, Preferred: cefazolin (150 mg/kg/day every 8 hours) or Preferred: oral cephalexin (75–100 mg/kg/day methicillin susceptible semisynthetic penicillin, eg oxacillin in 3 or 4 doses); (combination therapy not (150–200 mg/kg/day every 6–8 hours); well studied) Alternative: oral clindamycina Alternatives: clindamycina (40 mg/kg/day every (30–40 mg/kg/day in 3 or 4 doses) 6–8 hours) or >vancomycin (40–60 mg/kg/day every 6–8 hours)S. aureus, methicillin resistant, Preferred: vancomycin (40–60 mg/kg/day every Preferred: oral clindamycin (30–40 mg/kg/day susceptible to clindamycin 6–8 hours or dosing to achieve an AUC/MIC ratio of in 3 or 4 doses); (combination therapy not .400) or clindamycin (40 mg/kg/day every 6–8 hours); well-studied) Alternatives: oral linezolid Alternatives: linezolid (30 mg/kg/day every 8 hours (30 mg/kg/day in 3 doses for children for children ,12 years old and 20 mg/kg/day every ,12 years and 20 mg/kg/day in 2 doses 12 hours for children $12 years old) for children $12 years)S. aureus, methicillin resistant, Preferred: vancomycin (40–60 mg/kg/day every Preferred: oral linezolid (30 mg/kg/day in resistant to clindamycin 6-8 hours or dosing to achieve an AUC/MIC ratio of 3 doses for children ,12 years and (combination therapy not .400); 20 mg/kg/day in 2 doses for children well studied) $12 years old); Alternatives: linezolid (30 mg/kg/day every 8 hours for children ,12 years old and 20 mg/kg/day Alternatives: none; entire treatment course with every 12 hours for children $12 years old) parenteral therapy may be required Pediatric Community Pneumonia Guidelines d CID d e7
  8. 8. Table 5. (Continued) Oral therapy (step-down therapyPathogen Parenteral therapy or mild infection)Haemophilus influenza, typeable Preferred: intravenous ampicillin (150-200 mg/kg/day Preferred: amoxicillin (75-100 mg/kg/day in (A-F) or nontypeable every 6 hours) if b-lactamase negative, ceftriaxone 3 doses) if b-lactamase negative) or (50–100 mg/kg/day every 12-24 hours) if b-lactamase amoxicillin clavulanate (amoxicillin producing, or cefotaxime (150 mg/kg/day every component, 45 mg/kg/day in 3 doses or 8 hours); 90 mg/kg/day in 2 doses) if b-lactamase producing; Alternatives: intravenous ciprofloxacin (30 mg/kg/day every 12 hours) or intravenous levofloxacin Alternatives: cefdinir, cefixime, (16-20 mg/kg/day every 12 hours for cefpodoxime, or ceftibuten children 6 months to 5 years old and 8-10 mg/kg/day once daily for children 5 to 16 years old; maximum daily dose, 750 mg)Mycoplasma pneumoniae Preferred: intravenous azithromycin Preferred: azithromycin (10 mg/kg on day 1, (10 mg/kg on days 1 and 2 of therapy; followed by 5 mg/kg/day once daily on transition to oral therapy if possible); days 2–5); Alternatives: intravenous erythromycin lactobionate Alternatives: clarithromycin (20 mg/kg/day every 6 hours) or levofloxacin (15 mg/kg/day in 2 doses) or oral (16-20 mg/kg/day every 12 hours; maximum daily erythromycin (40 mg/kg/day in 4 doses); dose, 750 mg) for children .7 years old, doxycycline (2–4 mg/kg/day in 2 doses; for adolescents with skeletal maturity, levofloxacin (500 mg once daily) or moxifloxacin (400 mg once daily)Chlamydia trachomatis or Preferred: intravenous azithromycin Preferred: azithromycin (10 mg/kg on day 1, Chlamydophila pneumoniae (10 mg/kg on days 1 and 2 of therapy; followed by 5 mg/kg/day once daily Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011 transition to oral therapy if possible); days 2–5); Alternatives: intravenous erythromycin lactobionate Alternatives: clarithromycin (20 mg/kg/day every 6 hours) or levofloxacin (15 mg/kg/day in 2 doses) or oral (16-20 mg/kg/day in 2 doses for children 6 months erythromycin (40 mg/kg/day in 4 doses); to 5 years old and 8-10 mg/kg/day once daily for for children .7 years old, doxycycline children 5 to 16 years old; maximum daily dose, (2-4 mg/kg/day in 2 doses); for adolescents 750 mg) with skeletal maturity, levofloxacin (500 mg once daily) or moxifloxacin (400 mg once daily) Doses for oral therapy should not exceed adult doses. Abbreviations: AUC, area under the time vs. serum concentration curve; MIC, minimum inhibitory concentration. a Clindamycin resistance appears to be increasing in certain geographic areas among S. pneumoniae and S. aureus infections. b For b-lactam–allergic children.VI. How Can Resistance to Antimicrobials Be Minimized? VII. What Is the Appropriate Duration of Antimicrobial TherapyRecommendations for CAP? Recommendations 50. Antibiotic exposure selects for antibiotic resistance;therefore, limiting exposure to any antibiotic, whenever 54. Treatment courses of 10 days have been best studied,possible, is preferred. (strong recommendation; moderate-quality although shorter courses may be just as effective, particularlyevidence) for more mild disease managed on an outpatient basis. (strong 51. Limiting the spectrum of activity of antimicrobials to recommendation; moderate-quality evidence)that specifically required to treat the identified pathogen is 55. Infections caused by certain pathogens, notably CA-preferred. (strong recommendation; low-quality evidence) MRSA, may require longer treatment than those caused by 52. Using the proper dosage of antimicrobial to be able to S. pneumoniae. (strong recommendation; moderate-qualityachieve a minimal effective concentration at the site of infection evidence)is important to decrease the development of resistance. (strongrecommendation; low-quality evidence) VIII. How Should the Clinician Follow the Child With CAP for the Expected Response to Therapy? 53. Treatment for the shortest effective duration will Recommendationminimize exposure of both pathogens and normal microbiotato antimicrobials and minimize the selection for resistance. 56. Children on adequate therapy should demonstrate clinical(strong recommendation; low-quality evidence) and laboratory signs of improvement within 48–72 hours. Fore8 d CID d Bradley et al
  9. 9. Table 6. Influenza Antiviral Therapy Dosing recommendations Treatment ProphylaxisaDrug [186187] Formulation Children Adults Children AdultsOseltamivir 75-mg capsule; $24 months old: 150 mg/day in #15 kg: 30 mg/day; .15 to 75 mg/day (Tamiflu) 60 mg/5 mL 4 mg/kg/day in 2 doses for 23 kg: 45 mg/day; .23 to once daily Suspension 2 doses, for a 5 days 40 kg: 60 mg/day; .40 kg: 5-day treatment 75 mg/day (once daily in course each group) #15 kg: 60 mg/day; .15 to 23 kg: 90 mg/day; .23 to 40 kg: 120 mg/day; .40 kg: 150 mg/day (divided into 2 doses for each group) 9–23 months old: 9–23 months old: 3.5 mg/kg 7 mg/kg/day in once daily; 3–8 months old: 2 doses; 0–8 months 3 mg/kg once daily; not old: 6 mg/kg/day in routinely recommended for 2 doses; premature infants ,3 months old infants: 2 mg/kg/day owing to limited data in in 2 doses this age groupZanamivir 5 mg per inhalation, $7 years old: 2 inhalations 2 inhalations $5 years old: 2 inhalations 2 inhalations (Relenza) using a Diskhaler (10 mg total per dose), (10 mg total per (10 mg total per dose), (10 mg total twice daily for 5 days dose), twice daily once daily for 10 days per dose), for 5 days once daily Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011 for 10 daysAmantadine 100-mg tablet; 1–9 years old: 5–8 mg/kg/day 200 mg/day, as 1–9 years old: Same as (Symmetrel)b 50 mg/5 mL as single daily dose or in single daily dose same as treatment suspension 2 doses, not to exceed or in 2 doses treatment dose; dose 150 mg/day; 9–12 years old: 9–12 years old: 200 mg/day in 2 doses (not same as studied as single daily dose) treatment doseRimantadine 100-mg tablet; Not FDA approved for 200 mg/day, either FDA approved for 200 mg/day, (Flumadine)b 50 mg/5 mL treatment in children, but as a single daily prophylaxis down to as single suspension published data exist on safety dose, or divided 12 months of age. daily dose and efficacy in children; into 2 doses 1–9 years old: or in suspension: 1–9 years old: 5 mg/kg/day 2 doses 6.6 mg/kg/day once daily, not to exceed (maximum 150 mg/kg/day) in 150 mg; $10 years old: 2 doses; $10 years old: 200 mg/day as single daily 200 mg/day, as single daily dose or in 2 doses dose or in 2 doses NOTE. Check Centers for Disease Control and Prevention Website (http://www.flu.gov/) for current susceptibility data. a In children for whom prophylaxis is indicated, antiviral drugs should be continued for the duration of known influenza activity in the community because of thepotential for repeated and unknown exposures or until immunity can be achieved after immunization. b Amantadine and rimantadine should be used for treatment and prophylaxis only in winter seasons during which a majority of influenza A virus strains isolatedare adamantine susceptible; the adamantanes should not be used for primary therapy because of the rapid emergence of resistance. However, for patients requiringadamantane therapy, a treatment course of 7 days is suggested, or until 24–48 hours after the disappearance of signs and symptoms.children whose condition deteriorates after admission and but chest radiography should be used to confirm the presence ofinitiation of antimicrobial therapy or who show no pleural fluid. If the chest radiograph is not conclusive, thenimprovement within 48–72 hours, further investigation should further imaging with chest ultrasound or computedbe performed. (strong recommendation; moderate-quality evidence) tomography (CT) is recommended. (strong recommendation; high-quality evidence)ADJUNCTIVE SURGICAL AND NON–ANTI-INFECTIVE THERAPY FOR PEDIATRIC CAP X. What Factors Are Important in Determining Whether Drainage of the Parapneumonic Effusion Is Required?IX. How Should a Parapneumonic Effusion Be Identified? RecommendationsRecommendation 58. The size of the effusion is an important factor that 57. History and physical examination may be suggestive of determines management (Table 8, Figure 1). (strongparapneumonic effusion in children suspected of having CAP, recommendation; moderate-quality evidence) Pediatric Community Pneumonia Guidelines d CID d e9
  10. 10. Table 7. Empiric Therapy for Pediatric Community-Acquired Pneumonia (CAP) Empiric therapy Presumed bacterial Presumed atypical Presumed influenzaSite of care pneumonia pneumonia pneumoniaaOutpatient ,5 years old (preschool) Amoxicillin, oral (90 mg/kg/day Azithromycin oral (10 mg/kg on Oseltamivir in 2 dosesb) day 1, followed by 5 mg/kg/day once daily on days 2–5); Alternative: oral amoxicillin clavulanate Alternatives: oral clarithromycin (amoxicillin component, (15 mg/kg/day in 2 doses 90 mg/kg/day in 2 dosesb) for 7-14 days) or oral erythromycin (40 mg/kg/day in 4 doses) $5 years old Oral amoxicillin (90 mg/kg/day in Oral azithromycin (10 mg/kg on Oseltamivir or zanamivir 2 dosesb to a maximum day 1, followed by 5 mg/kg/day (for children 7 years of 4 g/dayc); for children once daily on days 2–5 to a and older); alternatives: with presumed bacterial maximum of 500 mg on day 1, peramivir, oseltamivir CAP who do not have clinical, followed by 250 mg on days 2–5); and zanamivir laboratory, or radiographic alternatives: oral clarithromycin (all intravenous) are evidence that distinguishes (15 mg/kg/day in 2 doses to a under clinical bacterial CAP from maximum of 1 g/day); investigation in children; atypical CAP, a macrolide erythromycin, doxycycline for intravenous zanamivir can be added to a b-lactam children .7 years old available for antibiotic for empiric therapy; compassionate use alternative: oral amoxicillin clavulanate (amoxicillin Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011 component, 90 mg/kg/day in 2 dosesb to a maximum dose of 4000 mg/day, eg, one 2000-mg tablet twice dailyb)Inpatient (all ages)d Fully immunized with Ampicillin or penicillin G; Azithromycin (in addition to Oseltamivir or zanamivir conjugate vaccines for alternatives: b-lactam, if diagnosis of (for children $7 years old; Haemophilus influenzae ceftriaxone or cefotaxime; atypical pneumonia is in alternatives: peramivir, type b and Streptococcus addition of vancomycin or doubt); alternatives: oseltamivir and pneumoniae; local clindamycin for clarithromycin or zanamivir (all intravenous) penicillin resistance in suspected CA-MRSA erythromycin; are under clinical invasive strains of doxycycline for children investigation pneumococcus is minimal .7 years old; levofloxacin in children; intravenous for children who have zanamivir available for reached growth maturity, compassionate use or who cannot tolerate macrolides Not fully immunized for H, Ceftriaxone or cefotaxime; addition of Azithromycin (in addition to As above influenzae type b and vancomycin or clindamycin for b-lactam, if diagnosis in S. pneumoniae; local suspected CA-MRSA; alternative: doubt); alternatives: penicillin resistance in levofloxacin; addition of vancomycin clarithromycin or erythromycin; invasive strains of or clindamycin for suspected doxycycline for children .7 years pneumococcus is CA-MRSA old; levofloxacin for children significant who have reached growth maturity or who cannot tolerate macrolides For children with drug allergy to recommended therapy, see Evidence Summary for Section V. Anti-Infective Therapy. For children with a history of possible,nonserious allergic reactions to amoxicillin, treatment is not well defined and should be individualized. Options include a trial of amoxicillin under medicalobservation; a trial of an oral cephalosporin that has substantial activity against S. pneumoniae, such as cefpodoxime, cefprozil, or cefuroxime, provided undermedical supervision; treatment with levofloxacin; treatment with linezolid; treatment with clindamycin (if susceptible); or treatment with a macrolide (if susceptible).For children with bacteremic pneumococcal pneumonia, particular caution should be exercised in selecting alternatives to amoxicillin, given the potential forsecondary sites of infection, including meningitis. Abbreviation: CA-MRSA, community-associated methicillin-resistant Staphylococcus aureus. a See Table 6 for dosages. b See text for discussion of dosage recommendations based on local susceptibility data. Twice daily dosing of amoxicillin or amoxicillin clavulanate may beeffective for pneumococci that are susceptible to penicillin. c Not evaluated prospectively for safety. d See Table 5 for dosages.e10 d CID d Bradley et al
  11. 11. Table 8. Factors Associated with Outcomes and Indication for Drainage of Parapneumonic Effusions Risk of poor Tube drainage with orSize of effusion Bacteriology outcome without fibrinolysis or VATSaSmall: ,10 mm on lateral Bacterial culture and Gram Low No; sampling of pleural fluid is not decubitus radiograph or stain results unknown or routinely required opacifies less than negative one-fourth of hemithoraxModerate: .10 mm rim of Bacterial culture and/or Gram Low to moderate No, if the patient has no respiratory fluid but opacifies less than stain results negative or compromise and the pleural fluid half of the hemithorax positive (empyema) is not consistent with empyema (sampling of pleural fluid by simple thoracentesis may help determine presence or absence of empyema and need for a drainage procedure, and sampling with a drainage catheter may provide both diagnostic and therapeutic benefit); Yes, if the patient has respiratory compromise or if pleural fluid is consistent with empyemaLarge: opacifies more than Bacterial culture and/or Gram High Yes in most cases half of the hemithorax stain results positive (empyema) a VATS, video-assisted thoracoscopic surgery. 59. The child’s degree of respiratory compromise is an 65. Moderate parapneumonic effusions associated with Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011important factor that determines management of parapneumonic respiratory distress, large parapneumonic effusions, oreffusions (Table 8, Figure 1) (strong recommendation; moderate- documented purulent effusions should be drained. (strongquality evidence) recommendation; moderate-quality evidence) 66. Both chest thoracostomy tube drainage with the additionXI. What Laboratory Testing Should Be Performed on Pleural of fibrinolytic agents and VATS have been demonstrated to beFluid? effective methods of treatment. The choice of drainage procedureRecommendation depends on local expertise. Both of these methods are associated with decreased morbidity compared with chest tube drainage 60. Gram stain and bacterial culture of pleural fluid should alone. However, in patients with moderate-to-large effusions thatbe performed whenever a pleural fluid specimen is obtained. are free flowing (no loculations), placement of a chest tube(strong recommendation; high-quality evidence) without fibrinolytic agents is a reasonable first option. (strong 61. Antigen testing or nucleic acid amplification through recommendation; high-quality evidence)polymerase chain reaction (PCR) increase the detection ofpathogens in pleural fluid and may be useful for management. XIII. When Should VATS or Open Decortication Be Considered in(strong recommendation; moderate-quality evidence) Patients Who Have Had Chest Tube Drainage, With or Without 62. Analysis of pleural fluid parameters, such as pH and Fibrinolytic Therapy?levels of glucose, protein, and lactate dehydrogenase, rarely Recommendationchange patient management and are not recommended. (weakrecommendation; very low-quality evidence) 67. VATS should be performed when there is persistence of 63. Analysis of the pleural fluid white blood cell (WBC) count, moderate-large effusions and ongoing respiratory compromisewith cell differential analysis, is recommended primarily to help despite 2–3 days of management with a chest tube anddifferentiate bacterial from mycobacterial etiologies and from ´ completion of fibrinolytic therapy. Open chest debridementmalignancy. (weak recommendation; moderate-quality evidence) with decortication represents another option for management of these children but is associated with higher morbidity rates. (strong recommendation; low-quality evidence)XII. What Are the Drainage Options for Parapneumonic Effusions?Recommendations XIV. When Should a Chest Tube Be Removed Either After Primary Drainage or VATS? 64. Small, uncomplicated parapneumonic effusions shouldnot routinely be drained and can be treated with antibiotic therapy 68. A chest tube can be removed in the absence of analone. (strong recommendation; moderate-quality evidence) intrathoracic air leak and when pleural fluid drainage is Pediatric Community Pneumonia Guidelines d CID d e11
  12. 12. Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011Figure 1. Management of pneumonia with parapneumonic effusion; abx, antibiotics; CT, computed tomography; dx, diagnosis; IV, intravenous; US,ultrasound; VATS, video-assisted thoracoscopic surgery.,1 mL/kg/24 h, usually calculated over the last 12 hours. MANAGEMENT OF THE CHILD NOT(strong recommendation; very low-quality evidence) RESPONDING TO TREATMENTXV. What Antibiotic Therapy and Duration Is Indicated for the XVI. What Is the Appropriate Management of a Child Who Is NotTreatment of Parapneumonic Effusion/Empyema? Responding to Treatment for CAP?Recommendations Recommendation 69. When the blood or pleural fluid bacterial culture identifies 72. Children who are not responding to initial therapy aftera pathogenic isolate, antibiotic susceptibility should be used to 48–72 hours should be managed by one or more of the following:determine the antibiotic regimen. (strong recommendation; high-quality evidence) a. Clinical and laboratory assessment of the current 70. In the case of culture-negative parapneumonic effusions, severity of illness and anticipated progression in order toantibiotic selection should be based on the treatment determine whether higher levels of care or support arerecommendations for patients hospitalized with CAP (see required. (strong recommendation; low-quality evidence)Evidence Summary for Recommendations 46–49). (strong b. Imaging evaluation to assess the extent and progressionrecommendation; moderate-quality evidence) of the pneumonic or parapneumonic process. (weak 71. The duration of antibiotic treatment depends on the recommendation; low-quality evidence)adequacy of drainage and on the clinical response c. Further investigation to identify whether the originaldemonstrated for each patient. In most children, antibiotic pathogen persists, the original pathogen has developedtreatment for 2–4 weeks is adequate. (strong recommendation; resistance to the agent used, or there is a new secondarylow-quality evidence) infecting agent. (weak recommendation; low-quality evidence)e12 d CID d Bradley et al
  13. 13. 73. A BAL specimen should be obtained for Gram stain and are able to administer and children are able to complyculture for the mechanically ventilated child. (strong adequately with taking those antibiotics before discharge.recommendation; moderate-quality evidence) (weak recommendation; very low-quality evidence) 74. A percutaneous lung aspirate should be obtained for Gram 83. For children who have had a chest tube and meet thestain and culture in the persistently and seriously ill child for requirements listed above, hospital discharge is appropriatewhom previous investigations have not yielded a microbiologic after the chest tube has been removed for 12–24 hours, eitherdiagnosis. (weak recommendation; low-quality evidence) if there is no clinical evidence of deterioration since removal or 75. An open lung biopsy for Gram stain and culture should if a chest radiograph, obtained for clinical concerns, showsbe obtained in the persistently and critically ill, mechanically no significant reaccumulation of a parapneumonic effusionventilated child in whom previous investigations have not or pneumothorax. (strong recommendation; very low-qualityyielded a microbiologic diagnosis. (weak recommendation; evidence)low-quality evidence) 84. In infants and children with barriers to care, including concern about careful observation at home, inability to complyXVII. How Should Nonresponders With Pulmonary Abscess or with therapy, or lack of availability for follow-up, these issuesNecrotizing Pneumonia Be Managed? should be identified and addressed before discharge. (weakRecommendation recommendation; very low-quality evidence) 76. A pulmonary abscess or necrotizing pneumonia identifiedin a nonresponding patient can be initially treated with XIX. When Is Parenteral Outpatient Therapy Indicated, Inintravenous antibiotics. Well-defined peripheral abscesses Contrast to Oral Step-Down Therapy?without connection to the bronchial tree may be drained under Recommendationsimaging-guided procedures either by aspiration or with a drainage 85. Outpatient parenteral antibiotic therapy should be Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011catheter that remains in place, but most abscesses will drain offered to families of children no longer requiring skilledthrough the bronchial tree and heal without surgical or invasive nursing care in an acute care facility but with a demonstratedintervention. (weak recommendation; very low-quality evidence) need for ongoing parenteral therapy. (weak recommendation; moderate-quality evidence) 86. Outpatient parenteral antibiotic therapy should beDISCHARGE CRITERIA offered through a skilled pediatric home nursing program or through daily intramuscular injections at an appropriateXVIII. When Can a Hospitalized Child With CAP Be Safely pediatric outpatient facility. (weak recommendation; low-qualityDischarged? evidence)Recommendations 87. Conversion to oral outpatient step-down therapy when 77. Patients are eligible for discharge when they have possible, is preferred to parenteral outpatient therapy. (strongdocumented overall clinical improvement, including level of recommendation; low-quality evidence)activity, appetite, and decreased fever for at least 12–24 hours.(strong recommendation; very low-quality evidence) 78. Patients are eligible for discharge when they demonstrate PREVENTIONconsistent pulse oximetry measurements .90% in room air XX. Can Pediatric CAP Be Prevented?for at least 12–24 hours. (strong recommendation; moderate- Recommendationsquality evidence) 79. Patients are eligible for discharge only if they demonstrate 88. Children should be immunized with vaccines for bacterialstable and/or baseline mental status. (strong recommendation; pathogens, including S. pneumoniae, Haemophilus influenzaevery low-quality evidence) type b, and pertussis to prevent CAP. (strong recommendation; 80. Patients are not eligible for discharge if they have high-quality evidence)substantially increased work of breathing or sustained tachypnea 89. All infants $6 months of age and all children andor tachycardia (strong recommendation; high-quality evidence) adolescents should be immunized annually with vaccines for 81. Patients should have documentation that they can tolerate influenza virus to prevent CAP. (strong recommendation; high-their home anti-infective regimen, whether oral or intravenous, quality evidence)and home oxygen regimen, if applicable, before hospital 90. Parents and caretakers of infants ,6 months of age,discharge. (strong recommendation; low-quality evidence) including pregnant adolescents, should be immunized with 82. For infants or young children requiring outpatient oral vaccines for influenza virus and pertussis to protect the infantsantibiotic therapy, clinicians should demonstrate that parents from exposure. (strong recommendation; weak-quality evidence) Pediatric Community Pneumonia Guidelines d CID d e13
  14. 14. 91. Pneumococcal CAP after influenza virus infection is a lower respiratory tract infection (LRTI), may also be defined indecreased by immunization against influenza virus. (strong a way that is clinically oriented, to assist practitioners with di-recommendation; weak-quality evidence) agnosis and management. 92. High-risk infants should be provided immuneprophylaxis with respiratory syncytial virus (RSV)–specific Etiologymonoclonal antibody to decrease the risk of severe pneumonia Many pathogens are responsible for CAP in children, mostand hospitalization caused by RSV. (strong recommendation; prominently viruses and bacteria [6, 7, 14–18]. Investigatorshigh-quality evidence) have used a variety of laboratory tests to establish a microbial etiology of CAP. For example, diagnosis of pneumococcalINTRODUCTION pneumonia has been based on positive cultures of blood, anti- body responses, antigen detection, and nucleic acid detection.Burden of Disease Each test has different sensitivity, specificity, and positive andPneumonia is the single greatest cause of death in children negative predictive values that are dependent on the prevalenceworldwide [4]. Each year, .2 million children younger than of the pathogen at the time of testing. Therefore, comparing5 years die of pneumonia, representing 20% of all deaths in etiologies of pneumonia between published studies is challeng-children within this age group [5]. Although difficult to quan- ing. More recent investigations have used a variety of sensitivetify, it is believed that up to 155 million cases of pneumonia molecular techniques including nucleic acid detection, particu-occur in children every year worldwide [5]. larly for viral identification. In many children with LRTI, di- In the developed world, the annual incidence of pneumonia is agnostic testing may identify 2 or 3 pathogens, including3–4 cases per 100 children ,5 years old [6, 7]. In the United combinations of both viruses and bacteria, making it difficult toStates, outpatient visit rates for CAP between 1994–1995 and determine the significance of any single pathogen [19–21].2002–2003 were defined using International Classification of Furthermore, unique to pediatrics, the developing immune Downloaded from cid.oxfordjournals.org at IDSA on August 31, 2011Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) di- system and age-related exposures result in infection caused byagnosis codes and reported in the National Ambulatory Medical different bacterial and viral pathogens, requiring that the in-Care Survey and the National Hospital Ambulatory Medical cidence of CAP and potential pathogens be defined separatelyCare Survey and identified rates ranging from 74 to 92 per 1000 for each age group [7].children ,2 years old to 35–52 per 1000 children 3–6 years old The advent of polysaccharide-protein conjugate vaccines[8]. In 2006, the rate of hospitalization for CAP in children for H. influenzae type b and 7 serotypes of S. pneumoniaethrough age 18 years, using data from the Healthcare Cost (7-valent pneumococcal conjugate vaccine [PCV7]) dramat-Utilization Project’s Kids’ Inpatient Database, also based on ically decreased the incidence of infection, including CAP,ICD-9-CM discharge diagnosis codes, was 201.1 per 100 000 [9]. caused by these bacteria. Newer vaccines that protect againstInfants ,1 year old had the highest rate of hospitalization (912.9 a greater number of pneumococcal serotypes are in variousper 100 000) whereas children 13–18 years had the lowest rate stages of clinical development, with a newly licensed 13-valent(62.8 per 100 000) [9]. Data from the Centers for Disease pneumococcal conjugate vaccine (PCV13) available in theControl and Prevention (CDC) document that in 2006, United States. Reports of epidemiologic investigations on the525 infants and children ,15 years old died in the United States etiology of CAP before the widespread use of these vaccinesas a result of pneumonia and other lower respiratory tract in- cited S. pneumoniae as the most common documentedfections [10]. The reported incidence of pneumonia in children, bacterial pathogen, occurring in 4%–44% of all childrenboth pathogen specific and as a general diagnosis, varies across investigated [14–16, 18].published studies based on definitions used, tests performed, In some studies, viral etiologies of CAP have been docu-and the goals of the investigators. CAP in children in the United mented in up to 80% of children younger than 2 years; in contrast,States, the focus of these guidelines, is defined simply as the investigations of older children, 10–16 years, who had bothpresence of signs and symptoms of pneumonia in a previously clinical and radiographic evidence of pneumonia, documentedhealthy child caused by an infection that has been acquired a much lower percentage of viral pathogens [15, 16, 18, 20].outside of the hospital [11, 12]. However, pneumonia defi- Of viral pathogens, RSV is consistently the most frequentlynitions can also be designed to be very sensitive for epidemio- detected, representing up to 40% of identified pathogens in thoselogic considerations (eg, fever and cough) or very specific, as younger than 2 years, but rarely identified in older childrendefined by government regulatory agencies for approval of with CAP. Less frequently detected are adenoviruses, bocavirus,antimicrobials to treat pneumonia (eg, clinical symptoms and human metapneumovirus, influenza A and B viruses, para-signs in combination with radiologic documentation or mi- influenza viruses, coronaviruses and rhinovirus [14, 16, 18, 22, 23].crobiologic confirmation) [13]. Pneumonia, broadly defined as Epidemiologic investigations of hospitalized children with CAPe14 d CID d Bradley et al