DATE: October 2008
TEXAS CHILDREN'S HOSPITAL
EVIDENCE-BASED CLINICAL DECISION SUPPORT
COMMUNITY-ACQUIRED PNEUMONIA (CAP) CLINICAL GUIDELINE
Definition The presence of signs and symptoms of pneumonia
in a previously healthy child, due to an infection of the
pulmonary parenchyma that has been acquired outside of the
(1)
hospital.
Etiology The exact etiology of pneumonia is often unidentified
due to the difficulty of obtaining a direct culture of infected lung
tissue. Following the introduction of Prevnar®, the burden of
(1-2)
invasive pneumococcal disease has been reduced.
Currently,
mixed etiologies account for 30 to 50% of the children with
(1,3-5)
community-acquired pneumonia.
Mycoplasma pneumoniae
and Chlamydia pneumoniae are more common in school-age
(1)
children. Viruses are most often identified in children < 5 years
of age with respiratory syncytial virus (RSV) being the most
(1, 7-9)
common viral etiology in children < 3 years of age.
In the Southwestern United States data confirm the importance
of Streptococcus pneumoniae and atypical pathogens (M.
pneumoniae, C. pneumoniae) plus the frequent occurrence of
mixed infections in children with community-acquired pneumonia.
(10)
In children with parapneumonic effusion at Texas Children's
Hospital, Staphlyococcus aureus has become the most common
(11)
organism actually isolated.
Differential Diagnosis
Viral bronchiolitis
Tuberculosis (TB)
Pertussis
Foreign body
Guideline Eligibility Criteria
Age ≥ 60 days to 17 years
Healthy children without underlying conditions
Clinical findings of CAP
Guideline Exclusion Criteria
Aspiration
Recent hospitalization (< 7 days before the onset of illness)
Diagnostic Evaluation Pneumonia related pathogens vary in
incidence throughout the year but peak during January through
(10)
April in the Southwest United States.
Pathogens currently circulating in the local community should be
considered in the diagnostic evaluation.
Physical Examination:
The severity of pneumonia is based on overall clinical
appearance and behavior, including a child’s alertness,
respiratory effort, and ability to take oral fluids. A small
percentage of children < 5 years of age may present with
abdominal pain or with fever and no signs of respiratory illness.
(12)
Although wheezing is more common in children with asthma
it can be a manifestation of viral or mycoplasma pneumonia.
A complete physical examination should be performed. A
combination of clinical findings, including vital signs and pulse
oximetry, is most predictive in determining CAP including:
 Infants < 12 months: Nasal flaring, O2 sat < 96%, tachypnea
(RR > 50) and retractions
 Children 1 to 5 years: O2 sat< 96%, tachypnea (RR>40)
 Children > 5 years: O2 sat< 96%, tachypnea (RR>30)
Consider the presence of parapneumonic effusion or empyema
in children with pneumonia who present severely ill. Signs of
pleural effusion include dyspnea, dry cough and pain over the
chest wall, exaggerated by deep breathing, or coughing.
Auscultatory findings may include a friction rub (leathery, rough
inspiratory and expiratory breath sounds). Breath sounds may
(13-14)
also be diminished or absent over the affected areas.
Laboratory Tests
Empiric antibiotic therapy should not be delayed while awaiting
diagnostic test results. Laboratory tests and chest x-rays should
be ordered based on clinical findings. CBC should only be
considered when adjunctive information is necessary to help
(15-17)
decide whether to use antibiotics.
The likelihood of a
bacterial cause generally increases as WBC counts increase
3
(17-18)
above 15000/mm .
Blood cultures are not routinely
recommended in the evaluation of uncomplicated bacterial
(19)
pneumonia.
In children with more severe disease, a blood
culture may be helpful particularly if drawn prior to antibiotic
treatment. PPD should be placed with history of exposure to TB
including personal or family travel to TB prevalent areas.
Nasopharyngeal swab for pertussis PCR should be obtained in
children with cough lasting more than two weeks. Consider
diagnostic tests for pertussis when typical symptoms are
present.
History: Assess for
 Age of child
 Immunization status, especially S. pneumoniae and influenza
 Exposure to TB
© Evidence-Based Outcomes Center, 2008
Quality and Outcomes Center, Texas Children’s Hospital
1
DATE: October 2008
Critical Points of Evidence
Evidence Supports
Evidence Lacking/Inconclusive
S.aureus is the most common pathogen isolated in children with
Value of CBC for all children presenting with signs and symptoms of
(11)
(15-17)
parapneumonic effusions at Texas Children's Hospital
pneumonia
Atypical organisms as a cause of CAP in children as young as 2
For treatment of pediatric empyema with fibrinolytic therapy versus
10, 20-21)
(31)
years (
VATS
Use of penicillin (including amoxicillin) to treat uncomplicated
Effectiveness of short course antibiotic therapy for uncomplicated
(22-23)
(36)
pneumonia
pneumonia
Evidence Against
Early video-assisted thorascopic surgery (VATS) should be
considered for children with complicated pleural effusion or
Use of blood cultures in the evaluation of CAP, in an outpatient
(11, 24-27)
(19)
empyema
setting
(37)
Therapies directed towards airway clearance
Use of an antiviral such as oseltamivir within 48 hours of
(28)
symptom onset
Fibrinolytics is a useful therapy option for children with
(29-35)
empyema
Principles of Clinical Management
General
The clinical picture of children with community-acquired
pneumonia (CAP) is highly variable making the determination of
etiology difficult. The child’s age and severity of illness are
important factors to consider in diagnosing and managing this
(14)
disease.
(10, 38-39)
Treatment Recommendations
See Antibiotic Table on pages 4-5.
Antibiotic
Recommendations
for
Bacterial
CAP,
Uncomplicated- Outpatient
The effectiveness of high dose amoxicillin has been
demonstrated for acute otitis media and is considered a
(40-41)
reasonable option when treating other infections.
Resistance of S. pneumoniae to penicillin is mediated through
alterations in the penicillin-binding proteins. Using high-doses of
amoxicillin saturates the penicillin-binding proteins and is
(23)
therefore considered a reasonable antibiotic option.
 Infants 1 to 4 months should be treated with high-dose
amoxicillin + macrolide to cover S. pneumoniae and C.
(42)
trachomatis.
 Children > 4 months to 2 years should be treated with highdose amoxicillin for 10 days, to cover S. pneumoniae, the
(43)
most common etiologic cause of CAP.
 Children < 2 years who do not tolerate an initial dose of oral
antibiotics should be treated with an IM dose of ceftriaxone.





(44-46)
 Children ≥ 2 to 5 years should be treated with high-dose
amoxicillin for 10 days ± macrolide for 5 days, to cover S.
(47-49)
pneumoniae and atypical pathogens.
For optimal
coverage, children ≥ 2 years should be treated with
amoxicillin and a macrolide. When there is lesser concern, a
single antibiotic can be used. If there is no clinical
improvement within 24-48 hours, a second antibiotic should
be added to the treatment.
 Children > 5 years should be treated with amoxicillin for 10
days and a macrolide for 5 days, to cover S. pneumoniae and
(43, 47-49)
atypical pathogens.
 Allergies: Children with a Type I penicillin allergy should be
treated with azithromycin for 5 days ± clindamycin for 10
days. Children with non-Type I penicillin allergy should be
treated with cephalosporin for 10 days ± macrolide for 5 days.
© Evidence-Based Outcomes Center, 2008
Quality and Outcomes Center, Texas Children’s Hospital




Antibiotic Recommendations for Bacterial CAP, Uncomplicated
– Inpatient or Progressive Care
It is likely that otherwise healthy children with uncomplicated
pneumonia can be treated with β-lactam agents. The current
susceptibilty profile at Texas Children's Hospital shows that 55% of
S. pneumoniae isolates are susceptible to penicillin and 79% are
(39)
susceptible to cefOTAXime.
Pneumococcal resistance to
antibiotics has not been shown to affect clinical outcomes in children
(50)
(MIC < 2.0 μg/mL).
If complications of pneumonia are suspected
or pleural effusions are present, see Antibiotic Recommendations
for Pleural Effusions.
Based on expert consensus, infants 29 to 60 days should be treated
with ampicillin and cefOTAXime to treat neonatal and communityacquired pathogens.
Infants 1 to 4 months should be treated with cefOTAXime +
(42)
macrolide to cover S. pneumoniae and C. trachomatis.
Children > 4 months to 2 years should be treated with ampicillin or
(50-52)
cefOTAXime, to cover S. pneumoniae.
Children ≥ 2 to 5 years should be treated with ampicillin or
cefOTAXime ± macrolide, to cover S. pneumoniae and atypical
(50-52)
pathogens.
Children > 5 years should be treated with ampicillin or cefOTAXine +
macrolide to cover S. pneumoniae and atypical pathogens.
Transition child to oral antibiotics for a minimum 10 day course of
antibiotics when there are signs of clinical improvement and
defervescence, and the child is able tolerate PO.
Antibiotic Recommendations for Bacterial CAP, Intensive Care
Children < 2 years should be treated with cefOTAXime and
vancomycin, to cover S. pneumoniae and S. aureus.
Children ≥ 2 years should be treated with cefOTAXime and
vancomycin ± macrolide, to cover S. pneumoniae, S. aureaus, and
atypical pathogens.
Antibiotic Recommendations for Pleural Effusions
Treatment of children with CAP and small simple pleural effusions
should be the same as children with CAP and no effusion.
Children should be treated with clindamycin to cover S. aureus and
S. pneumoniae.
Ill appearing children should be treated with clindamycin and
cefOTAXime.
If child shows no signs of clinical improvement (i.e. persistent fever
and/or leukocytosis, continuing 02 requirement, progression of
radiographic findings) consider consulting Infectious Diseases and
consider vancomycin.
Transition child to oral antibiotics for a minimum of a three week
course of antibiotics when there are signs of clinical improvement
and defervescence, and the child is able to tolerate PO.
2
DATE: October 2008
Recommendations for Viral CAP
 Consider viral rapid tests based on patient’s history, time of
year, and epidemiology.
 Oseltamivir for influenza in children ≥ 1 year with onset of
(28)
symptoms < 48 hours.
Admission Criteria
 Unable to tolerate oral fluids and medications; severely
dehydrated
 Moderate or severe respiratory distress
 Failed outpatient antibiotic treatment
 Altered mental status
 Oxygen saturation consistently < 90 %
 Unsafe to send home/poor follow-up
Discharge Criteria
 Uncomplicated pneumonia
 Appropriate mental status for age
 Tolerating PO
 Appropriate support system (i.e. PMD, caregivers)
Other Therapies
 Therapies directed towards airway clearance (i.e. postural
drainage and chest physiotherapy) should not be used for
(37)
patients with uncomplicated pneumonia.
 Consider early video-assisted thorascopic surgery (VATS) for
(24-27)
children with complicated pleural effusion or empyema.
 Consider fibrinolytic therapy and thoracostomy tube for
(29-35)
children with complicated pleural effusion or empyema.
Consults and Referrals
 Consultation with an ID specialist is considered when
allergies or prior antibiotic non-responsiveness confound the
choice of therapy.
 Consultation with a pulmonary or surgery specialist is
appropriate when uncertain about management of an effusion
(53-54)
or persistent pneumonia.
© Evidence-Based Outcomes Center, 2008
Quality and Outcomes Center, Texas Children’s Hospital
Follow Up Care
 Children diagnosed with CAP who are not hospitalized should
follow up with their pediatrician within 24 to 48 hours
regardless of initiating antibiotic therapy.
 Follow up care is recommended for all children hospitalized
with CAP.
 The child who is not following the expected clinical course,
consider complications, viral etiology, TB, an alternative
diagnosis, or ineffective antibiotic treatment due to lack of
antibiotic coverage or resistance patterns.
Outcomes Measures
 Failure to respond to antibiotic treatment
- Unplanned readmit within 48 hours and type of antibiotic
- Unplanned clinic revisit within 48 hours and type of
antibiotic
 Need for surgery following fibrinolytic therapy and
thoracostomy tube
 Length of stay (inpatient, intensive care)
 Mortality rate
 Direct variable costs
Prevention
Up-to-date heptavalent conjugated pneumococcal vaccine
(55)
(PCV7, Prevnar®)
(28)
Up-to-date annual influenza vaccine
(56-58)
Stress importance of strict hand washing
Infection Control
Contact precautions are required for children with upper
(59)
respiratory symptoms
Droplet precautions are required if Pertussis is suspected AND
(59)
during influenza season in addition to contact precautions
(59)
Airborne precautions are required if TB is suspected
Caregiver Education
(60)
Encourage breast feeding with infants
(60)
Limit exposure to other children (i.e. day care)
Emphasize children should not be exposed to passive smoking;
(61)
explore smoking cessation options for parents
3
DATE: October 2008
Community-Acquired Pneumonia Antibiotic Table, Outpatient
(38-39, 62-63)
NOTE: Consider insurance/Medicaid formulary restrictions.
Outpatient Therapy: First Line
≥ 2 yrs = High dose amoxicillin ± macrolide
< 2 yrs = High-dose amoxicillin
Type I Penicillin Allergy
Non-Type I Penicillin Allergy
Medication
≥5 yrs = amoxicillin + macrolide
First Line: macrolide ± clindamycin
First Line: cephalosporin ± macrolide
Dosage Form and Flavor
Taste &
Aftertaste*(62-63)
Dose
Comments
* 1 = Good 5 = Horrible (≥3 Consider asking the pharmacy to flavor; if possible.)
Suspension (per 5 mL):
125, 200, 250 or 400 mg [Bubble Gum]
Amoxicillin
Infants & children:
Oral: 80-100 mg/kg/DAY divided every 8-12 h (MAX: 3 grams/DAY)
Chewable tablets:
125, 250 or 400 mg [Cherry Banana
Mint]
1
Avoid use in
patients with a
penicillin allergy
Adults:
Oral: 500 mg every 8 h or 875 mg every 12 h
Capsules: 250 or 500 mg
Tablets: 500 or 875 mg
Suspension (per 5 mL):
100 or 200 mg [Cherry Crème de
Vanilla Banana]
Azithromycin
Infants & children ≥ 6 months:
Oral: 10 mg/kg on day 1 (MAX: 500 mg/DAY) followed by 5 mg/kg/day once
daily on days 2-5 (MAX: 250 mg/DAY)
3
Tablets: 250, 500 or 600 mg
Extended Release Suspension: 2
gram
[Cherry Banana]
Suspension (per 5 mL):
125 or 250 mg [Fruit Punch]
Clarithromycin
Children ≥ 6 months:
Oral: 15 mg/kg/DAY divided every 12 h (MAX: 1000 mg/day)
3
Tablets: 250 or 500 mg
Adults:
Oral: 500 mg on day 1 followed by 250 mg daily on days 2-5 or 2 gram
extended release as a single dose
First Line in
patients with a
Type I penicillin
allergy (±
clindamycin)
Metallic Aftertaste
Adults:
Oral: 250 mg every 12 h or 1000 mg (two 500 mg extended release tablets)
once daily
Outpatient Therapy: Second Line
Medication
Dosage Form and Flavor
Taste &
Aftertaste*(62-63)
Dose
Comments
* 1 = Good 5 = Horrible (≥3 Consider asking the pharmacy to flavor; if possible.)
Suspension (per 5 mL):
125 or 250 mg [strawberry]
Cefdinir
Capsules: 300 mg
2
Adults:
Oral: 300 mg every 12 h or 600 mg once daily (MAX: 600 mg/DAY)
Infants & children ≥ 6 months:
Oral: 10 mg/kg/DAY divided every 12 h (MAX: 800 mg/DAY)
Suspension (per 5mL):
50 or 100mg [lemon creme]
CefPODoxime
Tablets: 100 or 200mg
4
Tablets: 250 or 500 mg
4
Injection ONLY:
1 or 2 gram
Solution (per 5 mL):
75 mg [cherry flavor]
Clindamycin
Capsules: 75, 150 or 300 mg
Adults:
Oral: 250-500 mg every 12 h
Infants >2 months & children:
I.M., I.V.: 50-100 mg/kg/DAY IV or IM daily divided every 12-24 h (MAX: 50
mg/kg/dose or 2 gram/dose)
N/A
Ceftriaxone
Adults:
Oral: 100-400 mg every 12 h (MAX: 800mg/DAY)
Infants & children ≥ 6 months:
Oral: 30 mg/kg/day divided every 12 h (MAX: 1gram/DAY)
Suspension (per 5 mL):
125 or 250 mg [Tutti-Frutti]
CefUROxime
Infants & children ≥ 6 months:
Oral: 14 mg/kg/DAY divided every 12 h or 14 mg/kg/DAY once daily (MAX: 600
mg/DAY)
Adults:
I.M., I.V.: 1 gram IV or IM once daily (usually in combination with a macrolide)
Infants & children:
Oral: 10-30 mg/kg/DAY divided every 6-8 hours (MAX: 1.8 gram/DAY)
5
Expert Consensus Dosing: 10-40 mg/kg/DAY divided every 6-8 hours (MAX:
1.8 gram/DAY)
3rd Generation
Caution use in
patients with a
Type I penicillin
allergy
3rd Generation
Caution use in
patients with a
Type I penicillin
allergy
2nd Generation
Caution use in
patients with a
Type I penicillin
allergy
3rd Generation
Caution use in
patients with a
Type I penicillin
allergy
May offer a onetime dose prior to
initiating oral
antibiotics
Add if
concerned for
MRSA, S. aureus
Major side effect:
Diarrhea
Adolescents &adults:
Oral: 150-450 mg/dose every 6-8 hours; (MAX: 1.8 gram/DAY)
© Evidence-Based Outcomes Center, 2008
Quality and Outcomes Center, Texas Children’s Hospital
4
DATE: October 2008
Community-Acquired Pneumonia Antibiotic Table, Inpatient
(38-39, 62-63)
NOTE: Consider insurance/Medicaid formulary restrictions.
Inpatient Therapy: Acute Care Status / Progressive Care Unit
Uncomplicated Pneumonia:
Complicated Pneumonia:
Medication
< 2 yrs = ampicillin or cefOTAXime
All patients: cefOTAXime & clindamycin
Taste &
Dosage Form and Flavor
Aftertaste*(62-63)
≥ 2 yrs = ampicillin or cefOTAXime ± macrolide
Dose
Comments
* 1 = Good 5 = Horrible (≥3 Consider asking the pharmacy to flavor; if possible.)
Ampicillin
Injection:
125, 250, or 500 mg
1 or 2 gram
Infants & children:
I.V.: 200 mg/kg/DAY divided every 6 h (MAX: 2 gram/dose or 12 gram/DAY)
N/A
Injection:
40 mg/mL or 200 mg/mL (Central Line)
N/A
CefOTAXime
Suspension (per 5 mL):
100 or 200 mg [Cherry Crème de
Vanilla Banana]
Adults:
I.V.: 1000 mg every 4-6 h (MAX: 2 gram/dose or 12 gram/DAY)
Infants > 1 month to Children 1 year:
I.V.: 75 mg/kg/dose every 8 h
Children ≥ 1 year:
I.V.: 50-75 mg/kg/dose every 8 h (MAX: 2 gram/dose)
Adults:
I.V.: Moderate to severe infection: 1-2 gram/dose every 6-8 h (MAX: 2
gram/dose) or
Life-threatening infection: 2 gram/dose every 4 h (MAX: 2 gram/dose or 12
gram/DAY)
Infants & children ≥ 6 months:
Oral: 10 mg/kg on day 1 (MAX: 500 mg/DAY) followed by 5 mg/kg/day once
daily on days 2-5 (MAX: 250 mg/DAY)
I.V.: 10 mg/kg/DAY once daily (MAX: 500 mg/dose)
Tablets: 250, 500 or 600 mg
Azithromycin
3
Extended Release Suspension: 2 gram
[Cherry Banana]
Injection:
125, 250, or 500 mg
1 or 2 gram
Suspension (per 5 mL):
125 or 250 mg [Fruit Punch]
Clarithromycin
Tablets: 250 or 500 mg
Avoid use in
patients with a
penicillin allergy
Caution use in
patients with a
Type I penicillin
allergy
First Line in
patients with a
Type I penicillin
allergy (±
clindamycin)
Adults:
Oral: 500 mg on day 1 followed by 250 mg daily on days 2-5 or 2 gram extended
release as a single dose
I.V.: 10 mg/kg/DAY once daily (MAX: 500 mg/dose)
Children ≥ 6 months:
Oral: 15 mg/kg/DAY divided every 12 h (MAX: 1000 mg/DAY)
3
Metallic Aftertaste
Solution (per 5mL):
75 mg [cherry flavor]
Adults:
Oral: 250 mg every 12 h or 1000 mg (two 500 mg extended release tablets)
once daily
Infants & children:
Oral: 10-30 mg/kg/DAY divided every 6-8 h (MAX: 1.8 grams/DAY)
I.M., I.V.: 25-40 mg/kg/DAY divided every 6-8 h (MAX: 2.7 grams/DAY)
Add if concerned
for MRSA, S.
aureus
Expert Consensus Dosing: 30-40 mg/kg/DAY divided every 6-8 h (MAX: 2.7
grams/DAY)
Major side effect:
Diarrhea
Capsules: 75, 150 or 300 mg
Clindamycin
5
Injection:
150 mg/mL (IM) , 18 mg/mL (IV)
Adolescents & adults:
Oral: 150-450 mg/dose every 6-8 h (MAX: 1.8 grams/DAY)
I.M., I.V.: 1.2-2.7grams/DAY in 2-4 divided doses
Inpatient Therapy: Intensive Care Status (PICU)
Medication
< 2 yrs = cefOTAXime& vancomycin
Taste &
Dosage Form and Flavor
Aftertaste*(62-63)
≥ 2 yrs = cefOTAXime & vancomycin ± macrolide
Dose
Comments
* 1 = Good 5 = Horrible (≥3 Consider asking the pharmacy to flavor; if possible.)
Injection:
40 mg/mL or 200 mg/mL (Central
Line)
N/A
CefOTAXime
Injection:
5 mg/mL
Vancomycin
Azithromycin
Infants >1 month to children 1 year:
I.V.: 75 mg/kg/dose every 8 h
Injection:
125, 250, or 500 mg
1 or 2 gram
N/A
N/A
Injection:
150 mg/mL (IM) , 18 mg/mL (IV)
Clindamycin
N/A
Children ≥ 1 year:
I.V.: 50-75 mg/kg/dose every 8 h (MAX: 2 gram/dose)
Caution use in
patients with a
Type I penicillin
allergy
Adults:
I.V.: Moderate to severe infection: 1-2 gram/dose every 6-8 h (MAX: 2
gram/dose) or
Life-threatening infection: 2 gram/dose every 4 h (MAX: 2 gram/dose or 12
gram/DAY)
Infants >2 months & children:
I.V.: 13-15 mg/kg/dose IV every 8 h (MAX: 1.5 gram/dose or 4 gram/DAY)
Adults:
I.V.: 13-15 mg/kg/dose IV every 8-12 h (MAX: 1.5 gram/dose or 4 gram/DAY)
Infants & children:
I.V.: 10 mg/kg/DAY once daily (MAX: 500 mg/dose)
Adults:
I.V.: 10 mg/kg/DAY once daily (MAX: 500 mg/dose)
Infants & children:
I.M., I.V.: 25-40 mg/kg/DAY divided every 6-8 h (MAX: 2.7 grams/DAY)
Expert Consensus Dosing: 30-40 mg/kg/DAY divided every 6-8 hours (MAX:
2.7 grams/DAY)
Add if concerned
for MRSA, S.
aureus
Major side effect:
Diarrhea
Adolescents & adults:
I.M., I.V.: 1.2-2.7 grams/DAY in 2-4 divided doses
© Evidence-Based Outcomes Center, 2008
Quality and Outcomes Center, Texas Children’s Hospital
5
DATE: October 2008
TCH Evidence- Based Clinical Decision Support
Clinical Algorithm for Community-Acquired Pneumonia (CAP)
* Based on history, time of year,
and epidemiology. Other tests
include: PPD, PCR ( i.e.
Pertussis, other ) and serologies
for specific pathogens.
Initial clinical
findings suggestive
of CAP
Begin
Manage as
appropriate to
clinical findings
( OFF Algorithm )
No
Yes
~ Complications of CAP
- Pleural effusion/empyema
- Respiratory failure
- Sepsis
- Lung abscess
- Pneumatocele
Suspect pleural
effusion~
Follow Presumed Infectious
Pleural Effusion Algorithm
Yes
No
Continuum of Respiratory Severity
Mild
Moderate
- Respiratory assessment
Rate
2-12 months < 40
1-5 years < 30
> 5 years < 20
Good air movement, loose rales/
crackles
Mild to no use of accessory
muscles/retractions, +/- nasal flaring
on inspiration
- Normal to mildly irritable behavior
- Pulse oximetry > 95% room air
- Normal color
- Respiratory assessment
Rate
2-12 months 40-50
1-5 years 30-40
> 5 years 20-30
Depressed air movement, crackles
Moderate intercostal retractions,
mild to moderate use of accessory
muscles, nasal flaring
- Irritable, agitated, restless
- Pulse oximetry 90 to 95% room air
- Pale to normal color
- Respiratory assessment
Rate
2-12 months > 60
1-5 years > 50
> 5 years > 30
Diminished or absent breath
sounds, severe crackles, prolonged
expiration
Severe intercostal and substernal
retractions, nasal flaring
- Lethargic
- Pulse oximetry < 90% room air
- Cyanotic, dusky color
Consider
Diagnostic Tests:
- CXR
- CBC diff
- Blood culture
- Viral rapid tests*
- PPD
- Other tests*
Diagnostic Tests:
- CXR
- CBC diff/plt
- Chem 7
- Blood culture
----------------------------------Consider:
- Viral rapid tests*
- Viral cultures*
- Bacterial cultures of
respiratory specimens
- Other tests*
Suspect typical/
atypical bacterial
CAP
No
Yes
PPD if history of
exposure
Initiate Antibiotic
Therapy^
Discharge Home
Follow up
with pediatrician
within 48 hours
^ Antibiotics for Outpatient Therapy
- age 1 to 4 months high dose amoxicillin +
macrolide for S. pneumoniae and C.
trachomatis
- age 4 months to 2 years high dose amoxicillin
for typical bacterial pathogens
- age ≥ 2 to 5 years high dose amoxicillin ±
macrolide for typical/atypical bacterial
pathogens
- > 5 years amoxicillin + macrolide
( See abx table, p.4 )
Viral CAP
suspected
Severe
Bacterial CAP
suspected
Consider
Viral rapid tests*
Initiate antiviral tx
if sx < 48 hours
Yes
Discharge Home
Follow up
© Evidence-Based Outcomes Center, 2008
with pediatrician
Quality and Outcomes Center, Texas Children’s
Hospital
within 48 hours
Suspect
complicated
pneumonia~
Yes
Initiate Antibiotic
Therapy
Follow Presumed
Infectious Pleural
Effusion Algorithm
Discharge Criteria:
Uncomplicated pneumonia
Appropriate mental status for age
Taking PO fluids
Appropriate support system
Admit for clinical
monitoring
if ill appearing OR
↑ work of breathing
No
Admit for IV
Antibiotics‡
‡
No
Antibiotics for Inpatient Therapy
- age 1 to 4 months cefOTAXime + macrolide
to cover S. pneumoniae and C. trachomatis
- age 4 months to 2 years ampicillin or
cefOTAXime for typical bacterial pathogens
- age ≥ 2 to 5 years ampicillin or
cefOTAXime ± macrolide for typical/atypical
bacterial pathogens
- > 5 years ampicillin or cefOTAXime +
macrolide ( See abx table, p.5 )
Observation OR
Admit for IV
Antibiotics‡
6
DATE: October 2008
TCH Evidence- Based Clinical Decision Support
Clinical Algorithm for Presumed Infectious Pleural Effusions
Complications of
Community-Acquired Pneumonia
- Pleural effusion/empyema
- Respiratory failure
- Sepsis
- Lung abscess
- Pneumatocele
Suspect Infectious
Pleural Effusion
CXR
CXR demonstrates
pleural effusion
Yes
Prepare for
admission
°Indications of Complicated
Effusion:
- Large effusion ( > 10-20% )
- Ill appearing
- Develops hypoxemia
- Worsening symptoms
OFF Algorithm/Return to
CAP Algorithm
No
Suspect complicated
effusion°
No
- Chest US
- Consider surgery
consultation
Yes
No
Need for
Intervention
Yes
- CBC diff/plt
- Chem 7
- Blood culture
- Initiate antibiotic
therapy◘
- Monitor clinically
Clinical improvement
Treat organized fluid collections
with VATS or fibrinolytics and
thoracostomy tube
Yes
- CBC diff/plt
- Chem 7
- Blood culture
- Initiate antibiotic therapy◘
-------------------------------------------------------Select:
- VATS and thoracostomy tube
- Fibrinolytics and thoracostomy tube
- Thoracentesis
- Percutaneous thoracostomy ( pigtail,
small drain, chest tube )
Yes
Successful
procedure
No
No
- Repeat chest x-ray
- Consider repeat chest US
- Consider ID, pulmonary
and/or surgery consultation
Consider ID, pulmonary
and/or surgery consultation
VATS
Continue antibiotic
therapy/clinical
monitoring until
discharge criteria∆ are
met
Key:
CAP- community-acquired pneumonia
ID- infectious disease
US- ultrasound
video-assisted
thorascopic
surgery
©VATSEvidence-Based
Outcomes
Center,
2008
Quality and Outcomes Center, Texas Children’s Hospital
Continue antibiotic
therapy/clinical
monitoring until
discharge criteria∆ are
met
◘
Antibiotics for Inpatient Therapy,
Pleural Effusions
- Clindamycin to cover S. aureus and
S. pneumoniae
- Clindamycin and cefOTAXime for ill
appearing children
∆
Discharge Criteria
- No oxygen requirement
- Tolerating PO
- Chest tube removed
- Appropriate mental status for age
- Signs of clinical improvement and
defervescence
- Appropriate support system ( PCP, 7
caregiver )
DATE: October 2008
References
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Quality and Outcomes Center, Texas Children’s Hospital
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DATE: October 2008
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30. Singh, M., Mathew, J. L., Chandra, S., Katariya, S., & Kumar, L. (2004). Randomized controlled trial of intrapleural streptokinase in
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31. Sonnappa, S., Cohen, G., Owens, C. M., van Doorn, C., Cairns, J., Stanojevic, S., et al. (2006). Comparison of urokinase and videoassisted thoracoscopic surgery for treatment of childhood empyema. American Journal of Respiratory and Critical Care
Medicine, 174, 221-227.
32. Thomson, A. H., Hull, J., Kumar, M. R., Wallis, C. & Balfour Lyn, I. M. (2002). Randomised trial of intrapleural urokinase in the
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33. Wang, J. N., Yao, C. T., Yeh, C. N., Liu, C. C., Wu, M. H., Chuang, H. Y., et al. (2006). Once-daily vs. twice-daily intrapleural
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International Journal of Clinical Practice, 60(10), 1225-1230.
34. Cohen, E., Weinstein, M., & Fisman, D. N. (2008). Cost-effectiveness of competing strategies for the treatment of pediatric empyema.
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35. Cochran, J. B., Tecklenburg, F. W., & Turner, R. B. (2003). Intrapleural instillation of fibrinolytic agents for treatment of pleural
empyema. Pediatr Crit Care Med, 4(1), 39-43.
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dose amoxicillin for therapy of acute otitis media in children. Pediatr Infect Dis J, 22(5), 405-412.
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49. Harris, J. A., Kolokathis, A., Campbell, M., Cassell, G. H., & Hammerschlag, M. R. (1998). Safety and efficacy of azithromycin in the
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51. Atkinson, M., Lakhanpaul, M., Smyth, A., Vyas, H., Weston, V., Sithole, J., et al. (2007). Comparison of oral amoxicillin and
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54. Byington, C. L., Spencer, L. Y., Johnson, T. A., Pavia, A. T., Allen, D., Mason, E. O., et al. (2002). An epidemiological investigation of
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th
55. AAP: American Academy of Pediatrics Red Book. 26 Edition, 2003.
56. Morton, J. L., & Schultz, A. A. (2004). Healthy hands: Use of alcohol gel as an adjunct to handwashing in elementary school children.
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57. Roberts, L., Smith, W., Jorm, L., Patel, M., Douglas, R. M., & McGilchrist, C. (2000). Effect of infection control measures on the
frequency of upper respiratory infection in child care: A randomized, controlled trial. Pediatrics, 105, 738-742.
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Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force,
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Quality and Outcomes Center, Texas Children’s Hospital
9
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References continued…
60. Levine, O. S., Farley, M., Harrison, L. H., Lefkowitz, L., McGeer, A., & Schwartz, B. (1999). Risk factors for invasive pneumococcal
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61. Almirall, J., González, C. A., Balanzó, X., & Bolíbar, I. (1999). Proportion of community-acquired pneumonia cases attributable to
tobacco smoking. Chest, 116, 375-379.
62. Steele, R. W. M., Thomas, M. P. P., & Begue, R. E. M. (2001). Compliance issues related to the selection of antibiotic suspensions for
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© Evidence-Based Outcomes Center, 2008
Quality and Outcomes Center, Texas Children’s Hospital
10
DATE: October 2008
Guideline Preparation
Evaluating the Quality of the Evidence
This guideline was prepared by the Evidence-Based (EB)
Clinical Decision Support Team in collaboration with content
experts at Texas Children’s Hospital. Development of this
guideline supports the TCH Quality and Patient Safety Program
initiative to promote clinical guidelines and outcomes that build a
culture of quality and safety within the organization.
The Critical Appraisal Skills Program (CASP) criteria were
used to evaluate the quality of articles reviewed. Application
of the CASP criteria are completed by rating each reviewed
study or review as:
Strong study/systematic review - well designed, well
conducted, adequate sample size, reliable measures, valid
results, appropriate analysis, and clinically
applicable/relevant.
Study/systematic review with minor limitations specifically lacking in one of the above criteria
Study/systematic review with major limitations specifically lacking in several of the above criteria.
Published clinical guidelines evaluated for this review using
the AGREE criteria. The summary of these guidelines are
found at the end of this document. AGREE criteria uses a 14 point likert scale to evaluate 23 questions evaluating:
Guideline Scope and Purpose, Stakeholder Involvement,
Rigor of Development, Clarity and Presentation, Applicability,
and Editorial Independence. The higher the score the more
comprehensive the guideline.
Community-Acquired Pneumonia Content Expert Team
Aderonke Adekunle-Ojo, MD, Emergency Medicine
Christopher Baldez, LCSW, Social Work
Sara Bork, PharmD, Pharmacy
Darrell Cass, MD, Pediatric Surgery
Christopher Cassady, MD, Radiology
Emily Charles, Care Coordinator, Care Management
Michael Chance, Quality Improvement Specialist, Quality and
Outcomes Measurement
Kim Davis, RT, Respiratory Care
Leland Fan, MD, Pulmonary
Tiffany Helme, RN, Emergency Center
Curtis Kennedy, MD, Critical Care Medicine
Daniel Lemke, MD, Emergency Medicine
Ned Nuchtern, MD, Pediatric Surgery
Flor Munoz-Rivas, MD, Infectious Diseases
Elena Ocampo, MD, Cardiology
Shea Palamountain, MD, Texas Children’s Pediatric Associates
Ricardo Quinonez, MD, Pediatric Hospital Medicine
Elaine Whaley, RN, Infection Control
EB Clinical Decision Support Team
Quinn Franklin, MS, CCLS Research Specialist
Marilyn Hockenberry, PhD, RN, PNP-CS, FAAN Co-Chair
Development Process
This guideline was developed using the process outlined in the
EB Clinical Decision Support Manual (2007). The review
summary documents the following steps:
1. Review Preparation
-PICO questions established
-Evidence search confirmed with content experts
2. Review of Existing Internal and External Guidelines
- British Thoracic Society (BTS) guidelines and a published
guideline from a children’s hospital
3. Literature Review of Relevant Evidence
-Searched: Medline, Cochrane, AHRQ, CINAHL, Trip, Best
BETS, AAP, BMJ Clinical Evidence, Google Scholar
4. Critically Analyze the Evidence
- BTS Guidelines, Cincinnati Guideline, three systematic
reviews, one meta-analysis, nine randomized control trials,
and twenty-one non-randomized studies.
5. Summarize the Evidence by preparing the guideline, order
sets and interdisciplinary plan of care
-Materials used in the development of the guidelines, review
summaries and content expert team meeting minutes are
maintained in an community-acquired pneumonia EB
review manual with the Quality and Outcomes Center.
© Evidence-Based Outcomes Center, 2008
Quality and Outcomes Center, Texas Children’s Hospital
This guideline specifically summarizes the evidence in
support of or against specific interventions and identifies
where evidence is lacking/inconclusive. The following
categories describe how research findings provide support for
treatment interventions.
“Evidence that supports” the guideline (p.2) provides clear
evidence from more than one well-done randomized
controlled trial (RCT) (based on CASP criteria) that the
benefits of the intervention exceed harm.
“Evidence against” (p.2) provides clear evidence from more
than one well-done RCT (based on CASP criteria) that the
intervention is likely to be ineffective or that it is harmful.
“Evidence lacking/inconclusive” (p.2) indicates there is
currently insufficient data or inadequate data to recommend
for or against specific intervention.
Recommendations
Recommendations for the guidelines were developed by a
consensus process directed by the existing evidence, content
experts and patient and family preference when possible. The
Content Expert Team and EB Clinical Decision Support Team
remain aware of the controversies in the management of
community-acquired pneumonia in children. When evidence
is lacking, options in care are provided in the guideline and
the order sets that accompany the guideline.
Approval Process
Guidelines are reviewed and approved by the Content Expert
Team, EB Clinical Decision Support Team, EB Executive
Steering Committee, Pharmacy and Therapeutics Committee
and other appropriate hospital committees as deemed
appropriate for the guideline’s intended use. Guidelines are
reviewed and updated as necessary every 2 to 3 years within
the EB Clinical Decision Support Team at Texas Children’s
Hospital. Content Expert Teams will be involved with every
review and update.
Disclaimer
Guideline recommendations are made from the best
evidence, expert opinions and consideration for the patients
and families cared for within TCH/TCPA. The guideline is
NOT intended to impose standards of care preventing
selective variation in practice that are necessary to meet the
unique needs of individual patients. The physician must
consider each patient’s circumstance to make the ultimate
judgment regarding best care.
11