• Cincinnati Children's Hospital Medical Center. Evidence based care guideline for community acquired pneumonia in children 60 days through 17 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Jul. 16 p. [80 references]

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Evidence-based clinical practice guideline of community-acquired pneumonia in children 60 days to 17 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2000. 11 p.

The guideline was reviewed for currency in July 2006, using updated literature searches, and was determined to be current.

Each recommendation is followed by evidence classification (A-X) identifying the type of supporting evidence. Definitions for the types of evidence are presented at the end of the "Major Recommendations" field.

Assessment and Diagnosis

General

The objective of the initial clinical assessment is to decide if the child's history and physical examination findings are suggestive of community acquired pneumonia (CAP).

Clinical Assessment

1. It is recommended that the initial history include:
   • age of child (Juven et al., 2000 [C])
   • season of the year (Kim et al., 1996 [C])
   • microorganisms currently circulating in the community (Cincinnati area information is posted on Cincinnati Children's Hospital Medical Center (CCHMC's) CenterLink webpage: "What's Bugging Us?") (Local Expert Consensus [E])
   • immunization status, especially vaccines for Streptococcus pneumoniae and influenza virus if the child has an indication for these vaccines (Lucero et al., 2004 [M]; Harper et al., 2005 [S]), and
   • exposure to tuberculosis, including personal or family travel in areas where tuberculosis is prevalent (Local Expert Consensus [E]).
2. It is recommended that a physical examination be initially performed for signs of respiratory illness and for fever (Local Expert Consensus [E]).

   Note 1: Respiratory rates are best determined over a full 60-second period and inconsistencies require repeated observations. Respiratory patterns and rates in children are frequently modified by periodic behavioral and physiologic factors (Taylor et al., 1995 [C]; Singhi et al., 1994 [C]; Morley et al., 1990 [C]; Zukin et al., 1986 [C]; Leventhal, 1982 [C]; Berman, Simoes, & Lanata, 1991 [S,E]). See the Table below.

   Note 2: Any single clinical finding is not useful in determining if a child does or does not have pneumonia; combinations of clinical findings are more predictive (Margolis & Gadomski, 1998 [M]). See Appendix 1 in the original guideline document.

   Note 3: The best individual examination measures in children less than 5 years are:

   • nasal flaring (age <12 months)
   • oxygen saturation less than 94%
   • tachypnea, and
   • retractions

   (Mahabee-Gittens et al., 2005 [C]; Redd et al., 1994 [C]; Harari et al., 1991 [C]).

   The best negative predictive value is obtained if there is an absence of:

   • tachypnea alone, or
   • all other signs of respiratory illness

   (Margolis & Gadomski, 1998 [M]).

   See Appendix 1 in the original guideline document.

   Note 4: See Appendix 2 in the original guideline document for standardized lung sound nomenclature.

Table: World Health Organization Age-Specific Criteria for Tachypnea*

*Tachypnea may not be present in a child with pronounced retractions or other signs of increased work of breathing (World Health Organization, 1999 [E]).

3. It is recommended that the severity of pneumonia be assessed based on overall clinical appearance and behavior, including an assessment of the child's degree of alertness and willingness to accept feedings. Subcostal retractions and other evidence of increased work of breathing increase the likelihood of a more severe form of pneumonia (World Health Organization 1999 [E]).
4. It is recommended that children be assessed with an awareness that a small proportion of patients under five years of age may present without signs of respiratory illness (Bachur, Perry, & Harper, 1999 [D]). In acutely ill and febrile children, pneumonia also may present as pain referred to the abdomen or as fever without a source (Ravichandran & Burge, 1996 [D]; Jona & Belin, 1976 [D]; Local Expert Consensus [E]).

Radiologic Assessment

5. It is recommended, for children with clinical evidence of pneumonia, that chest x-rays be obtained when:
   • clinical findings are ambiguous
   • a complication such as a pleural effusion is suspected, or
   • pneumonia is prolonged and unresponsive to antimicrobials

   (Swingler, Hussey, & Zwarenstein, 1998 [A]; Alario et al., 1987 [C]; Bachur, Perry, & Harper, 1999 [D]).

   Note 1: In most studies of pneumonia, a positive chest x-ray was necessary to qualify a patient for study entry (Margolis & Gadomski, 1998 [M]; Redd et al., 1994 [C]). This constraint makes it difficult to assess the degree to which chest x-rays are actually needed to diagnose pneumonia in a clinical setting, since the likelihood ratio of a reference standard cannot be measured.

   Note 2: Chest x-rays have not consistently been shown to alter management decisions, nor to improve clinical outcomes (Swingler, Hussey, & Zwarenstein, 1998 [A]).

   Note 3: Chest x-rays have not been shown to differentiate viral from other etiologies (Virkki et al., 2002 [C]; Korppi et al., 1993 [C]; Alario et al., 1987 [C]; Bettenay, de Campo, & McCrossin, 1988 [D]).

   Note 4: The perceived need for and ordering of a chest x-ray is expected to be inversely and appropriately related to the clinician's experience with the diagnosis and treatment of CAP (Margolis & Gadomski, 1998 [M]; Local Expert Consensus [E]).

6. It is recommended that chest x-rays be considered in children less than 5 years of age with high fevers and high white blood cell (WBC) counts of uncertain source (Bachur, Perry, & Harper, 1999 [D]).

Laboratory Assessment

7. It is recommended that a white blood cell count and differential be considered only when adjunctive information is necessary to help decide whether to use antibiotics (Korppi, 2004 [C]; Toikka et al., 2000 [C]; Bachur, Perry, & Harper, 1999 [D]).

   Note: The likelihood of a bacterial cause generally increases as WBC counts increase above 15,000/mm³, especially above 20,000/mm³ and when associated with fevers higher than 39 degrees C (102.2 degrees F) (Shuttleworth & Charney, 1971 [C]; Bachur, Perry, & Harper, 1999 [D]), but these relationships have not been documented in all studies (Wubbel et al., 1999 [A]; Ruuskanen & Mertsola, 1999 [S,E]).

8. It is recommended that blood cultures not be routinely obtained (Claesson et al., 1989 [C]; Hickey, Bowman, & Smith, 1996 [D]).

   Note 1: When pneumonia is diagnosed in an outpatient setting, the likelihood of a positive blood culture is less than 2.7% (Hickey, Bowman, & Smith, 1996 [D]).

   Note 2: Blood cultures may be helpful for inpatients with more severe, resistant, or other unusual forms of pneumonia. Their utility, however, is limited when antibiotics are administered prior to obtaining the specimen (Kuppermann et al., 1997 [C]; Local Expert Consensus [E]).

9. It is recommended that C reactive protein (CRP), erythrocyte sedimentation rate (ESR), and other measures of acute phase reactants not be performed, as these tests are not specific enough to be useful (Korppi, 2004 [C]; Korppi, Remes, & Heiskanen-Kosma, 2003 [C]; Virkki et al., 2002 [C]; Heiskanen-Kosma & Korppi, 2000 [C]; Toikka et al., 2000 [C]; Korppi, Heiskanen-Kosma, & Leinonen, 1997 [C]; Ruuskanen & Mertsola, 1999 [S,E]).
10. It is recommended that cultures, rapid viral studies, or serologic testing for specific pathogens not be routinely performed, because the results, especially those that are not immediately available, usually do not affect initial management decisions (Honda et al., 2000 [D]; Skerrett, 1999 [S,E]; Bartlett et al., 1998 [S,E]).
11. It is recommended that purified protein derivative (PPD) and other skin testing be conducted in children with a history of exposure to tuberculosis, including personal or family travel in areas where tuberculosis is prevalent (Alves dos Santos et al., 2004 [D]; Local Expert Consensus [E]).
12. It is recommended that sputum Gram stain and culture on high quality specimens be considered when managing children with more severe disease (Skerrett, 1999 [S,E]; Local Expert Consensus [E]). See Consult and Referrals section.

    Note: A high quality sputum is usually defined by the presence of less than 10 squamous epithelial cells and greater than 25 white blood cells per low power field (Skerrett, 1999 [S,E]).

13. It is recommended, that pleural cultures be considered prior to starting antibiotics when managing a child with an effusion (Skerrett, 1999 [S,E]; Local Expert Consensus [E]). See Consult and Referrals section.
14. It is recommended that when historical, physical, radiologic, or laboratory findings are inconsistent, additional studies be considered to evaluate for alternative or coincident conditions, such as foreign body aspiration or immunodeficiency (Local Expert Consensus [E]).

Management

General

There is substantial overlap in the clinical presentation of pneumonias caused by different etiologies, making prediction of etiology based on clinical presentation and radiologic and laboratory assessment very difficult. Choice of antibiotic in the treatment of CAP is generally based on age of patient and severity of illness.

Medications -- age 60 days to 5 years

15. It is recommended, for children 60 days to 5 years of age, that high dose amoxicillin (80 to 90 mg/kg/day) be used for 7 to 10 days when a bacterial cause for CAP is likely. This treatment will cover S. pneumoniae, the most common etiology for CAP for children in this age range (Aurangzeb & Hameed, 2003 [A]; Bartlett & Mundy, 1995 [S,E]; Local Expert Consensus [E]). See Appendix 3 in the original guideline document.

    Note 1: The following resistance patterns have been reported:

    • 16.7% to 35% of S. pneumoniae isolates from patients with community acquired respiratory tract infections (all ages) in the U.S. are resistant to penicillins (Gordon, Biedenbach, & Jones, 2003 [C]).
    • Twenty-six percent of S. pneumoniae isolates from blood/cerebrospinal fluid (CSF) specimens cultured at CCHMC in 2004 were resistant to penicillin (CCHMC, 2004 [O]).
    • At least 15% of S. pneumoniae in the U.S. are resistant to macrolides (Hyde et al., 2001 [O]).
    • An organism resistant to penicillin is often resistant also to erythromycin. Erythromycin resistance generally suggests resistance to all macrolides (Doern et al., 1996 [C]; Campbell & Silberman,1998 [S]).

    Note 2: The effectiveness of high dose amoxicillin has been demonstrated for acute otitis media and is considered a reasonable option when treating other infections (Piglansky et al., 2003 [C]; Jadavji et al., 1997 [S,E]; Local Expert Consensus [E]). Resistance of S. pneumoniae to penicillin (including amoxicillin) is mediated through alterations in the penicillin-binding proteins. Using high doses of amoxicillin saturates the penicillin-binding proteins, and is therefore considered a reasonable antibiotic option (Pallares et al., 1995 [C]).

    Note 3: For children with allergies to penicillin, a macrolide or cephalosporin may be considered (Dudas et al., 2000 [C]; Klein, 1997 [S,E]; Local Expert Consensus [E]). See Consult and Referrals section if other antibiotics are being considered.

    Note 4: Because Mycoplasma pneumoniae or Chlamydia (Chlamydophila) pneumoniae are a less common cause of CAP in children under age 5 years, macrolides are not considered first line therapy (Esposito et al., 2002 [C]). A macrolide could be added to amoxicillin therapy at the 24 to 48 hour follow up if M. pneumoniae or C. pneumoniae is then suspected. This practice will avoid overuse of macrolides in this age group while adequately protecting the young child from resistant S. pneumoniae (Wubbel et al., 1999 [A]; Harris et al., 1998 [A]; Local Expert Consensus [E]).

    Note 5: For an infant or child unable to tolerate liquids, a single initial dose of ceftriaxone may be considered prior to starting oral antibiotics (Baskin, O'Rourke, & Fleisher, 1992 [C]; Chumpa, Bachur, & Harper, 1999 [D]; Local Expert Consensus [E]).

Medications -- age 5 years and older

16. It is recommended, for children age 5 years and older, that a macrolide be used to treat CAP. This treatment will cover M. pneumoniae and C. pneumoniae, the most common etiologies of CAP for children in this age group. A macrolide may also cover S. pneumoniae, the most common bacterial cause of CAP in all age groups. Treatment duration is 7 to 10 days, although a five-day course of azithromycin may be used (Wubbel et al., 1999 [A]; Harris et al., 1998 [A]; Klein, 1997 [S,E]). See Appendix 3 in the original guideline document.

    Note 1: The following resistance patterns have been reported:

    • At least 15% of S. pneumoniae in the U.S. are resistant to macrolides (Hyde et al., 2001 [O]).
    • 16.7% to 35% of S. pneumoniae isolates from patients with community acquired respiratory tract infections (all ages) in the U.S. are resistant to penicillins (Gordon, Biedenbach, & Jones, 2003 [C]).
    • Twenty-six percent of S. pneumoniae isolates from blood/cerebrospinal fluid (CSF) specimens cultured at CCHMC in 2004 were resistant to penicillin (CCHMC, 2004 [O]).
    • An organism resistant to penicillin is often resistant also to erythromycin. Erythromycin resistance generally suggests resistance to all macrolides (Doern et al., 1996 [C]; Campbell & Silberman, 1998 [S]).
    • For high dose amoxicillin discussion see the recommendation for the younger age group.

    Note 2: There is no evidence that any macrolide is more efficacious than another for treating M. pneumoniae or C. pneumoniae (Wubbel et al., 1999 [A]; Harris et al., 1998 [A]; Block et al., 1995 [A]; Klein, 1997 [S,E]).

Medications -- more severe disease

17. It is recommended, in a child with a more severe case of CAP (see recommendation #3), that the combination of both a macrolide and a beta-lactam agent (such as high dose amoxicillin or ceftriaxone) be considered. This will provide better coverage for resistant organisms and mixed infections (Korppi, Heiskanen-Kosma, & Kleemola, 2004 [C]; Heiskanen-Kosma, Korppi & Leinonen, 2003 [C]; Juven et al., 2000 [C]; Local Expert Consensus [E]).

    Note: Mixed etiologies are reported in 30% to 50% of children with CAP (Korppi, Heiskanen-Kosma & Kleemola, 2004 [C]; Heiskanen-Kosma, Korppi, & Leinonen, 2003 [C]; Juven et al., 2000 [C]).

Other Therapies

18. It is recommended that therapies directed toward airway clearance, such as postural drainage and chest physiotherapy (CPT), not be used for the patient with uncomplicated pneumonia (Hardy et al., 1994 [S,E]; Local Expert Consensus [E]).

Admission Criteria

19. It is recommended that hospital admission be especially considered for infants and children who:
    • have oxygen saturation consistently less than 91%
    • are severely dehydrated
    • are moderately dehydrated and unable to hydrate themselves orally after intravenous (IV) hydration
    • are in moderate or severe respiratory distress
    • have failed outpatient antibiotic treatment, or
    • the clinician or family have identified that it is unsafe to send home

    (Local Expert Consensus, [E]).

Follow up

20. It is recommended that practitioners follow up within 24 to 48 hours all patients diagnosed with CAP, including those not initially started on antibiotics (Local Expert Consensus, [E]).

    Note: Evaluation of the child not following the expected clinical course may include consideration of:

    • alternative diagnosis (Alves dos Santos et al., 2004 [D])
    • ineffective antibiotic treatment because of lack of antibiotic coverage for the actual etiology
    • ineffective antibiotic treatment because of organisms resistant to either penicillins or macrolides (Hyde et al., 2001 [O])
    • complication(s); or
    • viral etiology

    (Local Expert Consensus [E]).

Consults and Referrals

21. It is recommended that consultation with a specialist in pediatric infectious diseases be considered when allergies, comorbid conditions, or prior antibiotic non-responsiveness confound the choice of therapy for a specific patient (Local Expert Consensus, [E]).
22. It is recommended that consultation with a specialist in pediatric pulmonary diseases is appropriate when uncertain about the management of an effusion (Byington et al., 2002 [D]; Hardie et al., 1996 [D])

Prevention and Education

23. It is recommended that immunizations which prevent CAP be kept up-to-date, including:
    • heptavalent conjugated pneumococcal vaccine (PCV7, Prevnar®), (American Academy of Pediatrics [AAP], 2003 [O]); and
    • annual influenza vaccine for
      • all children 6 to 23 months of age, and
      • children aged >6 months with certain risk factors (including but not limited to asthma, cardiac disease, sickle cell disease, human immunodeficiency virus [HIV] and diabetes)

    (Harper et al., 2005 [S]).

24. It is recommended that measures to prevent pneumonia infections be discussed with families, including:
    • handwashing, especially when exposed to individuals with respiratory infections (Morton & Schultz, 2004 [A]; Roberts et al., 2000 [A])
    • breastfeeding (Levine et al., 1999 [C])
    • limiting exposure to other children (Levine et al., 1999 [C])

      Note: Spread of respiratory infections in daycare settings may be reduced by verifying the facility's handwashing policies and actual handwashing practices, selecting a setting with fewer children, and/or delaying entry into daycare (Roberts et al., 2000 [A]; Local Expert Consensus [E]).

    • reducing exposure to smoke (Almirall et al., 1999 [D]).

Definitions:

Evidence Grading Scale:

A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
E: Expert opinion or consensus
F: Basic laboratory research
S: Review article
M: Meta-analysis or systematic review
Q: Decision analysis
L: Legal requirement
O: Other evidence
X: No evidence

An algorithm is provided in the original guideline document for the medical management of children 60 days through 17 years of age with community acquired pneumonia (CAP).

The type of supporting evidence is identified for the recommendations (see "Major Recommendations" field).

Evidence Grading Scale:

A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
E: Expert opinion or consensus
F: Basic laboratory research
S: Review article
M: Meta-analysis or systematic review
Q: Decision analysis
L: Legal requirement
O: Other evidence
X: No evidence

• Cincinnati Children's Hospital Medical Center. Evidence based care guideline for community acquired pneumonia in children 60 days through 17 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Jul. 16 p. [80 references]

Not applicable: The guideline was not adapted from another source.

2000 Jul (revised 2005 Dec 22; reviewed 2006 Jul)

Cincinnati Children's Hospital Medical Center - Hospital/Medical Center

Cincinnati Children's Hospital Medical Center

Community Acquired Pneumonia Team 2005

Community Physicians: *Joseph Gibbons, MD, Chair

Cincinnati Children's Hospital Medical Center Physicians and Practitioners: *Melinda Mahabee-Gittens MD, Emergency Medicine; *William Hardie MD, Pulmonary Medicine; *Rebecca Brady, MD, Infectious Disease; *Alan Brody, MD, Radiology; *Omer Berger, MD, General Pediatrics

Residents: Katie Kerrey, MD, Chief; Tracie Butler, MD

Patient Services: Dawn Butler, PharmD, Pharmacy; *Scott Pettinichi, RRT, Dir. Respiratory Care; Shirley Salway, RN, BS

Division of Health Policy & Clinical Effectiveness Support: Eloise Clark, MPH, Facilitator; Danette Stanko, MA, MPH, Epidemiologist; *Kate Rich, Lead Decision Support Analyst; Detrice Barry, RN, MSN, Education Coordinator; Debbie Hacker, RN, Medical Reviewer; Gary Geis, MD, Methodologist, Emergency Medicine; Edward Donovan, MD, Medical Director, Clinical Effectiveness; Eduardo Mendez, RN, MPH, Dir. Evidence-Based Practice

All Team Members and Clinical Effectiveness support staff listed above have signed a conflict of interest declaration.

Ad Hoc Advisors: *Uma Kotagal, MBBS, MSc, VP, Division Director; Kieran Phelan, MD, General Pediatrics & Clinical Effectiveness; Mel Rutherford, Esq, VP, Risk Management; *Richard Ruddy, MD, Dir. Emergency Medicine; *Beverly Connelly, MD, Dir. Ped Infectious Diseases; *Thomas DeWitt, MD, Dir. General & Community Pediatrics; *Michael Farrell, MD, Chief of Staff; *Dorine Seaquist RN, VP, Patient Services; Raouf Amin, MD, Dir. Pulmonary Medicine; Joel Mortensen, PhD, Dir. Microbiology & Virology

*Member of previous Community Acquired Pneumonia guideline development Team

All Team Members and Clinical Effectiveness support staff listed have declared whether they have any conflict of interest and none were identified.

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Evidence-based clinical practice guideline of community-acquired pneumonia in children 60 days to 17 years of age. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2000. 11 p.

The guideline was reviewed for currency in July 2006, using updated literature searches, and was determined to be current.

This summary was completed by ECRI on March 15, 2001. The information was verified by the guideline developer as of June 15, 2001. This summary was updated by ECRI on February 3, 2006. The information was verified by the guideline developer on February 17, 2006. This summary was updated by ECRI on August 24, 2006. The updated information was verified by the guideline developer on September 5, 2006. This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium).