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Current Diagnosis & Treatment of

Community-Acquired Pneumonia
in Children
Highlights of the PIDS/IDSA National Guidelines


Samir S. Shah, MD, MSCE, FAAP
Professor, Department of Pediatrics
University of Cincinnati College of Medicine
Director, Division of Hospital Medicine
Cincinnati Children's Hospital Medical Center
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Disclaimers
Statements and opinions expressed are those of the authors and not
necessarily those of the American Academy of Pediatrics.

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Disclaimers continued
I have no financial conflicts of interest to disclose.
I have not received any compensation for preparing and presenting
this webinar.
I served as Associate Chair of the Pediatric Infectious Diseases
Society/Infectious Diseases Society of America Pneumonia
Guidelines Committee, the topic of this presentation.
Sources of current research support:
o National Institute of Allergy and Infectious Diseases
o Agency for Healthcare Research and Quality
o Childrens Hospitals Association
o Robert Wood Johnson Foundation

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Objectives
Discuss the rationale for creating pediatric
community-acquired pneumonia (CAP) national
guidelines.
Describe currently recommended diagnostic and
treatment strategies for CAP in the United States.
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Why Do We Need Guidelines?
Role of guidelines
o Assist in healthcare decision-making
o Reduce variation in clinical practice
o Lead to better patient care and outcomes
Only as good as the evidence on which they are
based
Most useful for conditions with substantial variation
in clinical practice and outcomes
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Context for the US Guidelines
CAP is the most common serious childhood infection
in the US.
o 3 million outpatient visits each year
o >150,000 hospitalizations each year
o Up to 15% of children hospitalized with CAP have a serious
pneumonia-associated complication such as empyema.
In the US, there is substantial variation across
hospitals and physicians in diagnosis, treatment, and
outcomes.
Kronman MP. Pediatrics. 2011; Shah SS. J Hosp Med. 2011; Lee GE. Pediatrics. 2010; Shah SS. Pediatr Pulmonol. 2010
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Diagnostic Testing for CAP at 43 US Hospitals
Brogan TV. Pediatr Infect Dis J. 2012
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Diagnostic Testing for CAP at 43 US Hospitals
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Diagnostic Testing for CAP at 43 US Hospitals
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Treatment for CAP at 43 US Hospitals
Data from Ambroggio LV, et al. Pediatr Infect Dis J. 2012
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Available Free Online and In Print
Guidelines available at: www.idsociety.org
Bradley JS, Byington CL, Shah SS, and Alverson B, Carter ER, Harrison C,
Kaplan SL, Mace S, McCracken G, Moore M, St. Peter S, Stockwell J,
Swanson JT. The management of community-acquired pneumonia in
infants and children older than 3 months of age: clinical practice
guidelines by the Pediatric Infectious Diseases Society and the Infectious
Diseases Society of America. Clin Infect Dis. 2011;53:e25e76
Bradley JS, Byington CL, Shah SS, and Alverson B, Carter ER, Harrison C,
Kaplan SL, Mace S, McCracken G, Moore M, St. Peter S, Stockwell J,
Swanson JT. Executive Summary: The management of community-
acquired pneumonia in infants and children older than 3 months of age:
clinical practice guidelines by the Pediatric Infectious Diseases Society and
the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:617
630
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Consensus Development Based on Evidence
92 recommendations
Consensus development based on evidence
o GRADE working group (Grading of Recommendations,
Assessment, Development, and Evaluation)
o Method of assigning strength of recommendation and
quality of evidence to each recommendation
Strength of Recommendation (Strong or Weak)
Quality of Evidence (High, Moderate, or Low)
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Evidence-Based Guidelines
Clinical Recommendations
o Site of care
o Diagnostic testing
o Anti-infective treatment
o Adjunctive treatment
o Management of the child not responding to treatment
o Discharge criteria
o Prevention
Future research
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Evidence-Based Guidelines
Clinical Recommendations
o Site of care
o Diagnostic testing
o Anti-infective treatment
o Adjunctive treatment
o Management of the child not responding to treatment
o Discharge criteria
o Prevention
Future research
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Outline
Diagnostic Testing
o Pulse oximetry
o Chest x-ray
o Blood culture
o Atypical bacteria testing
o Viral testing
o Complete blood counts

Anti-Infective Treatment
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Definition of CAP
CAP is the presence of signs and symptoms of
pneumonia in a previously healthy child due to an
infection acquired outside of the hospital.

Guideline scope
o Age 3 months 18 years
o Exclusionary conditions
Immune deficiency
Chronic lung disease (e.g., cystic fibrosis)
Mechanical ventilation
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Diagnostic TestingPulse Oximetry

Outpatient and Inpatient
Recommendation
Recommended
Comments
In all children with pneumonia
and suspected hypoxemia.

The presence of hypoxemia
should guide decisions and
further diagnostic testing.
Recommendation Strength
Strong
Evidence Quality
Moderate
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Initial Chest X-RayRecommendation

Outpatient Inpatient
Recommendation
NOT Recommended Recommended Recommended
Comments
For confirmation of
suspected CAP in
patient well enough to
be treated in
outpatient setting
(after evaluation in
office, clinic, or ED).
Patients with
hypoxemia, significant
respiratory distress,
and failed antibiotic
therapy; to verify
presence or absence
of complications.
All patients
hospitalized with CAP;
to document presence,
size, and character of
infiltrates and identify
complications that may
require interventions.
Strength
Strong Strong Strong
Evidence Quality
High Moderate Moderate
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Initial Chest X-RayRationale
Chest x-rays (CXRs) not routinely required for outpatient CAP
CXRs:
o Do not reliably distinguish bacterial from viral CAP or among the
various bacterial pathogens
o Impractical in office setting
Often requires travel to a separate facility
Barriers to physicians obtaining timely results
o CXR in outpatient setting infrequently changes clinical
management
Guideline provides guidance on when to perform CXR in
outpatient setting
Swingler GH. Cochrane Database Syst Rev. 2008; Swingler GH. Lancet. 1998; Novack V. J Intern Med. 2006; Alario AJ. J Pediatr. 1987;
Grossman LK. Ann Emerg Med. 1988
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Repeat Chest X-RayRecommendation
Outpatient AND Inpatient
Recommendation
NOT Recommended
Comments

Not routinely indicated in children
who recover uneventfully
Recommendation Strength Strong
Evidence Quality Moderate
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Repeat Chest X-RayRecommendation

Outpatient AND Inpatient
Recommendation
Recommended Recommended Recommended
Comments

For inadequate
clinical improvement,
progressive
symptoms, or clinical
deterioration within
4872 hours after
initiation of
antibiotics

In children with
complicated
pneumonia with
worsening
respiratory distress
or clinical instability

46 weeks after the
diagnosis of CAP in
limited circumstances
(e.g., recurrent
pneumonia in same
lobe or suspicion of an
anatomic anomaly)
Recommendation
Strength
Strong Strong Strong
Evidence Quality Moderate Low Moderate
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Repeat Chest X-RayRationale
Repeat CXRs commonly identify persistent or
residual abnormalities 36 weeks later.
o Abnormalities rarely alter management.
o Abnormalities do not predict treatment failure or worse
clinical outcome.
Repeat CXRs represent unnecessary radiation
exposure to infants and children.
Gibson NA. BMJ. 1993; Virkki R. Pediatr Pulmonol. 2005; Grossman LK. Pediatrics. 1979; Wacogne I. Arch Dis Child. 2003; Heaton P. N Z Med
J. 1998; Bruns AH. Clin Infect Dis. 2007
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Blood CulturesRecommendations

Outpatient Inpatient
Recommendation
NOT Recommended Recommended Recommended
Comments
Non-toxic, fully immunized
children treated as
outpatients

Failure to demonstrate
clinical improvement,
progressive symptoms,
or deterioration after
initiation of antibiotic
therapy

Requiring
hospitalization for
moderate-severe
bacterial CAP

Strength
Strong Strong Strong
Evidence Quality
Moderate Moderate Low
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Blood CulturesRationale
Outpatient
o Infrequently identifies pathogens (<2%)
o False-positives more common than true positives at some
hospitals
o Rarely informs outpatient management
Bonadio WA. Pediatr Emerg Care. 1988; Hickey RW. Ann Emerg Med. 1996; Shah SS. Arch Pediatr Adolesc Med. 2003; Shah SS. Pediatr Infect
Dis J. 2011
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Blood CulturesRationale
Outpatient
o Infrequently identifies pathogens (<2%)
o False-positives more common than true positives at some
hospitals
o Rarely informs outpatient management
Inpatient
o Positive in ~3% of uncomplicated pneumonia
o Positive in ~15% with empyema
o Allows for culture-directed therapy when positive
o Provides local epidemiologic data
Bonadio WA. Pediatr Emerg Care. 1988; Hickey RW. Ann Emerg Med. 1996; Shah SS. Arch Pediatr Adolesc Med. 2003; Shah SS. Pediatr Infect
Dis J. 2011
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Atypical Bacteria TestingRecommendation

Mycoplasma
pneumoniae
Chlamydophila
pneumoniae
Recommendation
Recommended NOT recommended
Comments

If signs/symptoms
consistent with but not
classic for Mycoplasma;
can help guide antibiotic
selection.

Reliable and readily
available diagnostic tests
do not currently exist.
Strength
Weak Strong
Evidence Quality
Moderate High
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Atypical Bacteria TestingRationale
Evolving understanding of M. pneumoniae
epidemiology
o Increasingly identified in younger children

Rapid tests (IgM and PCR) available
o Variable test accuracy
o Treatment is not mandatory, especially with low likelihood
of infection (e.g., negative test), as benefit of macrolide
antibiotics uncertain
Heiskanen-Kosma T. Pediatr Infect Dis J. 1998; Michelow IC. Pediatrics. 2004; Korppi M. Respirology. 2004; Thurman KA. Clin Infect Dis. 2009
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Viral TestingRecommendations

Influenza Other Respiratory Viruses
Recommendation
Recommended Recommended
Comments
Use sensitive and specific tests.
Positive influenza test may
decrease the need for additional
tests and antibiotic use, while
guiding the use of antiviral agents
in both outpatient and inpatient
settings.
Can modify clinical decision
making in children with suspected
pneumonia; antibiotics are not
required in the absence of
findings that suggest bacterial
co-infection.
Strength Strong Weak
Evidence Quality High Low
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Diagnostic TestingViral Pathogens
Antibacterial therapy is not necessary in children,
either outpatients or inpatients, with a positive test
for influenza virus in the absence of clinical,
laboratory, or radiographic findings that suggest
bacterial co-infection.

Strong recommendation; High-quality evidence
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Viral TestingRationale
Influenza testing
o Positive tests reduce antibiotic use and ancillary testing
(e.g., CXR, CBC) by >50%.
o Positive tests guide antiviral treatment decisions.
Early treatment improves outcomes.
Bonner AB. Pediatrics. 2003; Esposito S. Arch Dis Child. 2003; Iyer SB. Acad Emerg Med. 2006; Benito-Fernandez J. Pediatr Infect Dis J. 2006
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Viral TestingRecommendations

Influenza Other Respiratory Viruses
Recommendation
Recommended Recommended
Comments
Use sensitive and specific tests.
Positive influenza test may
decrease the need for additional
tests and antibiotic use, while
guiding the use of antiviral
agents in both outpatient and
inpatient settings.
Can modify clinical decision
making in children with suspected
pneumonia; antibiotics are not
required in the absence of
findings that suggest bacterial
co-infection.
Strength Strong Weak
Evidence Quality High Low
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Complete Blood CountRecommendation

Outpatient Inpatient
Recommendation
NOT Recommended NOT Recommended
Comments
However, may provide useful
information in those with more
serious disease for clinical
management in the context of
clinical exam and other laboratory
and imaging studies.
However, may provide useful
information for those with severe
pneumonia; to be interpreted in
the context of clinical exam and
other laboratory and imaging
studies.
Strength
Weak Weak
Evidence Quality
Low Low
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Complete Blood CountRationale
Anemia and thrombocytopenia may suggest
hemolytic-uremic syndrome.
o Rarely an occult process.
WBC count has poor specificity for diagnosis of
bacterial pneumonia.
o WBC elevated in many children with CAP.
o Most children with elevated WBC do not have CAP.
o WBC does not reliably distinguish bacterial from viral CAP.
Waters AM. J Pediatr. 2007; Banerjee R. Pediatr Infect Dis J. 2011; Korppi M. Eur Respir J. 1997
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Antibiotic ChoiceOutpatient
Age of Child
Infant / Preschool-Age School-Age
Recommendation No antibiotics Amoxicillin Amoxicillin Azithromycin
Comments

Antibiotics NOT
routinely
required
because viral
pathogens are
most prevalent.

First-line
therapy if
previously
healthy and
immunized.

Provides
excellent
coverage for
S. pneumoniae.

First-line
therapy if
previously
healthy and
immunized.

Consider
atypical
bacterial
pathogens.

For treatment
of older
children
with findings
compatible
with CAP
caused by
atypical
pathogens.
Strength Strong Strong Strong Weak
Evidence Quality High Moderate Moderate Moderate
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Antibiotic ChoiceOutpatient Alternatives
Allergy
Amoxicillin Azithromycin
Alternatives

2
nd
/3
rd
generation Cephalosporin
Clindamycin
Levofloxacin

Doxycycline (>7 years old)
Levofloxacin or Moxifloxacin

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Antibiotic ChoiceInpatient

First Line Second Line
Recommendation Ampicillin / PCN G 3
rd
Generation Cephalosporin
Comments
Immunized infant, preschool,
or school-age child.
Non-immunized, in regions
with high levels of PCN
resistant pneumococcal strains,
or in children with life-
threatening infection.
Non-beta lactam agents (e.g.,
vancomycin) are not needed for
the treatment of pneumococcal
pneumonia.
Strength Strong Weak
Evidence Quality Moderate Weak
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Antibiotic ChoiceInpatient Secondary Agents

Atypical Bacteria
S. aureus
Recommendation Macrolide Vancomycin or Clindamycin
Comments

In addition to beta-lactam
therapy if atypical bacteria
are significant
considerations. Instead of
beta-lactam if findings are
characteristic of atypical
infection.

In addition to beta-lactam
therapy if clinical,
laboratory, or imaging
characteristics are
consistent with infection
caused by S. aureus.
Recommendation
Strength
Weak Strong
Evidence Quality Moderate Low
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Antibiotic ChoiceRationale
S. pneumoniae remains most common bacterial cause of CAP
Decreasing S. pneumoniae antibiotic resistance
o >50% decrease in penicillin-non-susceptible infections
o >50% decrease strains in resistance to multiple antibiotics
Kyaw MH. N Engl J Med. 2006
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Antibiotic ChoiceRationale
Penicillin resistance is not associated with treatment
failure for non-CNS S. pneumoniae infections.
o In vitro, bactericidal activity achieved at low concentrations
relative to MIC
o In vivo, high and sustained concentrations achieved in
serum and lung
Amoxicillin administered at 80 mg/kg/day
Ampicillin administered at 300 mg/kg/day
Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Perez-Trallero E. J Chemother. 2001
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Antibiotic ChoiceRationale
Macrolide resistance and 2nd generation cephalosporin
resistance are associated with treatment failure for
non-CNS S. pneumoniae infections.
Vancomycin
o Not necessary for S. pneumoniae
o MRSA less common and rarely occult
o Challenges
Poor lung penetration compared with aminopenicillins
Associated with nephrotoxicity
May require monitoring trough concentrations or continuous infusion
Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Chung J. Anaesth Intensive Care. 2011
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Minimizing ResistanceDuration of Therapy
Treatment for the shortest effective duration will minimize exposure
of both pathogens and normal microbiota, and minimize the selection
for resistance.
Strong recommendation; Low-quality evidence
Treatment courses of 10 days have been best studied. Shorter courses
may be just as effective, particularly for more mild disease managed
on an outpatient basis.
Strong recommendation; Moderate-quality evidence
Infections caused by certain pathogens, notably CA-MRSA, may require
longer treatment than those caused by S. pneumoniae.
Strong recommendation; Moderate-quality evidence
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Final Thoughts
Guidelines are only as good as the
evidence on which they are based.
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Final Thoughts
Developing guidelines is relatively easy
compared to implementing them.
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Outpatient Bottom Line
Test Should I do it? Comment
Pulse oximetry Yes
CXR No Consider in some circumstances
Repeat CXR No Consider in some circumstances
Influenza testing Yes During influenza season
Mycoplasma Yes Encouraged if considering macrolide
Sputum No
Blood culture No Yes, if deterioration or no improvement
CBC No
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Outpatient Bottom Line
Role Antibiotic Comment
First-Line Amoxicillin
Alternate 2
nd
/3
rd
generation
cephalosporin; clindamycin;
levofloxacin
Alternate Macrolide Add to include coverage
for atypicals.
Alternate Macrolide Substitute to include
coverage for atypicals if
pneumococcal coverage is
not desired.
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Inpatient Bottom Line
Test Should I do it? Comment
Pulse oximetry Yes
CXR Yes
Repeat CXR No Consider in some circumstances
Influenza testing Yes During influenza season
Mycoplasma Yes Encouraged if considering macrolide
Sputum Yes If child can provide
Blood culture Yes
CBC No
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Inpatient Bottom Line
Role Antibiotic Comment
First-Line Ampicillin
Alternate Cefotaxime or Ceftriaxone If unimmunized
Alternate Macrolide Add to include coverage
for atypicals.
Alternate Macrolide Substitute to include
coverage for atypicals if
pneumococcal coverage is
not desired.
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Thank You!
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