Pneumonia » Clinical Guidelines

April 2014

References:

  1. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL Mace SE, McCracken Jr. GH, Moor MR, St. Peter SD, Stockwell JA, and Swanson JT. The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Disease Society of America. Clinical Infectious Disease. 2011 July. e1-e52.
  2. Seattle Children’s Hospital Community Acquired Pneumonia Pathway
  3. www.cdc.gov/flu
  4. Devitt M. PIDS and IDSA Issue Management Guidelines for Community-Acquired Pneumonia in Infants and Young Children. American Family Physician 2012, 86(2):196-202.
  5. Stuckey-Shrock K, Hayes BL, and George CM. Community-Acquired Pneumonia in Children. American Family Physician 2012, 86(7), 661-667.

Topic Owner: Mollie Grow MD MPH mollie.grow@seattlechildrens.org
(Prior: Florence Wu, MD florence.wu@gmail.com)


OBJECTIVES:

  1. Provide criteria for accurate diagnosis
  2. Provide criteria for hospitalization
  3. Outline appropriate, age-specific therapies
  4. Reduce unnecessary laboratory testing, radiography, and hospitalization
  5. Prevent complications of community acquired pneumonia

SUMMARY:

  1. Do not routinely obtain laboratory studies or radiographs in patients well enough to be treated as outpatients.
  2. High-dose amoxicillin is first line therapy for all children (regardless of immunization status).
  3. If ≥ 5 years old, consider adding coverage for atypical pneumonia with a macrolide (i.e., azithromycin).
  4. Consider rapid influenza testing if influenza is suspected in patients who would require treatment per CDC guidelines.
  1. Inclusion Criteria
    1. ≥ 3 months of age
  2. Exclusion Criteria
    1. < 3 months of age
    2. Immunocompromised
    3. Underlying lung disease other than asthma
    4. Mechanically ventilated
    5. Underlying neuromuscular disease
    6. Risk for aspiration pneumonia
    7. Complicated pneumonia (empyema, lung abscess)
  3. Assessment
    1. Definition: Acute infection (typically viral or bacterial) of the lung parenchyma acquired outside of the hospital
    2. Diagnosis: Pneumonia is a clinical diagnosis made in the setting of fever, tachypnea, increased work of breathing, cough, and abnormal lung sounds on auscultation.
    3. Diagnostic testing
      1. Perform pulse oximetry.
      2. Consider rapid influenza testing if influenza is suspected in patients who would require treatment per CDC guidelines (see Table 2).
      3. Do not routinely obtain a chest radiograph. Consider the use of chest x-ray if there is more clinical uncertainty and imaging will affect plans for management (i.e., reduce the need for antibiotics).
    4. If moderately/severely ill, transfer to hospital for additional testing
  4. Disposition
    1. Outpatient management recommended if ALL following criteria met:
      1. Tolerating PO
      2. Not hypoxemic (>90%)
      3. Normal or mildly increased work of breathing
    2. Indications for hospitalization:
      1. Respiratory distress (see table below)
      2. Hypoxemia (oxygen saturation ≤90%)
      3. Age 3-6 months
      4. Dehydration, vomiting, or not tolerating PO medications
      5. Suspected or documented MRSA infection
      6. Presence of co-morbid conditions
      7. Not tolerating enteral fluids and/or dehydrated
      8. Concerns for the family"s ability to adhere to recommended therapy, return for appropriate follow up, or seek/access emergency care
    3. Outpatient Management
      1. For bacterial pneumonia:
        1. In both fully and partially immunized children, high-dose amoxicillin 90mg/kg divided BID is considered acceptable first line therapy for outpatient management (note: TID therapy is provided for patients at SCH).
        2. In children who are penicillin-allergic, consider a 3rd generation cephalosporin (cefpodoxime 5mg/kg q 12 hours, max 200mg children, 400mg adolescents) or clindamycin (10 mg/kg/day q8 hours). May consider daily IM ceftriaxone (75mg/kg/day).
        3. Treatment duration is 10 days.
        4. If ≥ 5 years old, consider adding coverage for atypical pneumonia with a macrolide (i.e., azithromycin 10mg/kg day 1, 5mg/kg days 2-5).
        5. Clinical improvement on antibiotics is typically seen in 48-72 hours.
      2. For influenza, treat with an antiviral if appropriate per CDC guidelines.
        1. Given the known association between influenza and Staphylococcus aureus, if bacterial superinfection in the setting of known influenza infection is suspected, add amoxicillin-clavulanate.
    4. Re-assessment
      Patients who experience worsening of symptoms or lack of improvement after 48-72 hours of antibiotics are considered non-responders. In this situation,
      1. Obtain a 2-view chest x-ray.
      2. Re-evaluate need for hospitalization.
      3. Collect a sputum sample if child can expectorate.
      4. Consider resistant bacteria or atypical (fungal, mycobacterial, parasitic) pathogens.
      5. Consider pneumonia secondary to foreign body aspiration or an intrinsic airway obstruction.
    5. Other Considerations
      1. For children age ≤ 2 years, consider bronchiolitis rather than pneumonia in the presence of diffuse coarse breath sounds and/or wheezing.
      2. In the preschool age group, the vast majority of CAP is viral, so antibiotics are often not indicated and should be used judiciously.
      3. Avoid macrolide (i.e., azithromycin) monotherapy for CAP as it may be inadequate for Streptococcus pneumoniae.
      4. However, do consider using a macrolide alone if clear signs and symptoms of atypical pneumonia are present (symptoms >3 days, headache, non-focal exam, not ill-appearing) in a patient ≥ 5 years old.

Signs of Respiratory Distress

Antiviral therapy in Influenza

Flowchart

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