Consensus Guidelines for Inpatient Management of Community Acquired Pneumonia in Infants & Children > 3 Months

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Northern California Pediatric Hospital Medicine Consortium

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Table of Contents

• EXECUTIVE SUMMARY
• CLINICAL CONSENSUS GUIDELINES
• Criteria for Use of Inpatient Community-Acquired Pneumonia (CAP) Guidelines
• Site of Care Management Decisions
• Diagnostic Testing
• Antimicrobial Therapy
• Diagnosis of Effusion & Adjunctive Therapy
• Discharge Criteria / Discharge Planning
• Frequently Asked Questions
• References

Executive summary

Objectives

• Standardize and improve the quality of care of pediatric patients with uncomplicated community acquired pneumonia (CAP) in the outpatient and inpatient settings; specifically:

• Decrease unnecessary laboratory testing and imaging

• Standardize admission / discharge criteria to decrease unnecessary hospital days

• Decrease use of broad-spectrum antibiotics and use best available evidence to guide selection of appropriate antibiotic therapy

• Promote short courses of antibiotic therapy based on current evidence

Recommendations

• Do NOT routinely obtain laboratory testing or imaging in children with CAP who can be treated in the outpatient setting

• Consider obtaining blood culture in children with moderate to severe CAP requiring hospitalization

• Obtain PA and lateral chest x-ray in children requiring hospital admission for CAP

• Obtain SARS-CoV-2, influenza, and other respiratory viral testing in the evaluation of children with CAP as appropriate per local epidemiology

• Use Amoxicillin / Ampicillin for first-line treatment of uncomplicated, typical CAP in most children

• Use a 7-day course of antibiotics if admitted for uncomplicated CAP

• Discontinue use of continuous pulse oximetry monitoring in hospitalized patients who are clinically stable or improved and not requiring supplemental oxygen

• Convert from IV to PO antibiotics once patient is able to take enteral medication

Methods

This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.

Metrics Plan

Suggested data metrics to track implementation of these guidelines and to track quality and improvement

• Primary Measures
• Length of stay
• % of patients > 3 months old admitted with uncomplicated pneumonia with exclusive Ampicillin/amoxicillin usage starting on hospital day 1.
• Goal greater than or equal to 80%
• % of patients > 3 months old admitted with uncomplicated pneumonia discharged with total antibiotic course of 7 days.
• Goal greater than or equal to 80%
• Secondary Measure
• % of patients > 3 months old with discontinuation of continuous pulse oximetry within 6 hours of stopping supplemental oxygen.
• Goal greater than or equal to 50%
• Balancing Measures
• Visits to ED or readmission within 7 days of discharge.

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Consensus Clinical Guidelines

 

Criteria for Use of Inpatient Community-Acquired Pneumonia (CAP) Guidelines

• Age >3 months and < 20 years
• Community acquired infection (excludes hospital acquired, aspiration, other etiologies)
• Uncomplicated pneumonia (excludes moderate to large and/or loculated pleural effusion)
• NOTE: This guideline does not detail recommended antimicrobial therapy and other management for complicated PNA. However, it was created with the understanding that children with who are ultimately found to have complicated pneumonia may be admitted first to community hospitals, and therefore recommendations for initial antibiotic management and transfer decisions are provided in order to maximize its utility.
• Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy, or infection history

 

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Site of Care Management Decisions

• Indications for admission to inpatient setting:
• "moderate to severe" disease
• respiratory distress / increased work of breathing
• hypoxia (<90% on RA)
• "toxic" appearance
• dehydration / poor PO intake
• inability to tolerate PO therapy
• clinically failed appropriate PO antibiotic therapy (at least 48 hours)

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Diagnostic Testing

• Chest X-ray:
• NOT routinely indicated in outpatient setting
• PA & Lateral CXR indicated in all children upon admission to inpatient setting (for new diagnosis or worsening clinical symptoms / failed outpatient treatment)
• Repeat CXR should be obtained in children who fail to demonstrate improving fever curve or clinical improvement and in those who have progressive symptoms or clinical deterioration within 48-72 hours after initiation of antibiotic therapy
• Microbiologic Testing:
• Blood Culture (BCx):
• NOT indicated in outpatient setting
• Consider BCx on admission to inpatient setting in following situations:
• Complicated pneumonia
• Illness requiring ICU admission
• age < 3 months old
• Incomplete vaccines
• Balancing factors:
• (-) risk of contaminants
• (-) low yield
• (+ / -) potential change in management
• (+) opportunity to identify organism pre-antibiotic therapy
• Sputum sampling NOT routinely indicated
• Serum testing for Mycoplasma pneumoniae NOT routinely indicated for suspected atypical infections
• Viral testing
• Outpatient:
• Influenza (i.e., Flu) testing ROUTINELY recommended in patients during the influenza season with influenza-like illness at high risk of influenza complications; including patients < 2 years old, chronic medical conditions, immunocompromised, obese, pregnant, residents of chronic care facilities, and those on chronic aspirin therapy
• Please refer to yearly CDC guidelines for full list of risk factors and treatment with antivirals
• RSV testing: consider RSV testing for children < 3 yrs with compatible symptoms, especially if a positive result would lead to avoidance of antibiotic therapy
• Inpatient:
• Flu testing for all admissions indicated during influenza season;
• be aware of local testing methods and sensitivities
• Point of care tests (POCT) with an antigen test for Flu are less sensitive than molecular POCTs for Flu. If being admitted and initial antigen POCT was negative for Flu, flu testing should be repeated with a molecular test. No need to repeat if POCT antigen test is positive.
• Empiric antiviral therapy is recommended for influenza if patient is severely ill and admitted with compatible signs/symptoms, until influenza is ruled out by adequately sensitive test
• SARS-CoV 2

• RSV testing indicated during RSV season in patients < 3 years old with consistent symptoms especially if a positive result would lead to avoidance of antibiotic therapy

• Pulse Oximetry Monitoring:
• Indications for continuous pulse oximetry monitoring:
• Initial assessment (for period of 4hrs)
• Unstable clinical status
• Need for supplemental oxygen (O2 sat < 90%)
• Indications for spot O2 sat checks with periodic vital signs:
• Clinically stable patient and not requiring supplemental oxygen
• Patients not requiring supplemental oxygen > 4 hours

 

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Antimicrobial Therapy 

• It is recommended to use narrow spectrum antibiotics based on current epidemiology and susceptibilities; see Table 1 of Empiric Antibacterial Therapies for Pediatric CAP developed by the UCSF Benioff Children’s Hospital Pediatric Antimicrobial Stewardship Program
         NOTE: Children with suspected or confirmed viral PNA should generally NOT be treated with antibiotics
• Consider consultation with Peds ID if concurrent bacteremia, potentially immunocompromised, or more severe pneumonia

Table 1: EMPIRIC ANTIBACTERIAL THERAPY FOR PEDIATRIC CAP

Reference: UCSF Infectious Diseases Management Program

https://idmp.ucsf.edu/content/community-acquired-pneumonia

Outpatient Therapy

Inpatient Therapy, Uncomplicated CAP

Inpatient Therapy, Complicated CAP

Table references and links

+ Assessment of Antibiotic Allergies: https://idmp.ucsf.edu/content/assessment-antibiotic-allergies

^Oral Cephalosporins: https://idmp.ucsf.edu/content/oral-cephalosporin-options-respiratory-tract-infections

*Guidance on Amoxicillin maximum dosing and formulations: https://idmp.ucsf.edu/content/maximum-dosing-amoxicillin-and-amoxicillin-clavulanate

Neonatal Dosing Guideline: https://idmp.ucsf.edu/neonatal-antimicrobial-dosing-benioff-childrens-hospitals

Pertussis: https://idmp.ucsf.edu/content/pertussis

Influenza: https://idmp.ucsf.edu/content/influenza

Diagnosis of Effusion & Adjunctive Therapy

• Considerations if pneumonia is failing to improve (continued fever AND clinically not improved or worsening) after 48-72 hours:
1. Re-consider diagnosis of CAP - is there potentially another infectious or non-infectious source? Is it viral?
2. Consider evaluation of less common pulmonary infections e.g. tuberculosis, coccidioidomycosis, etc.
3. Consider evaluation for suppurative complication e.g., empyema which may develop/progress/not respond even on appropriate microbiologically-directed therapy.
• Diagnosis of effusion:
• History, exam, + CXR (PA+lateral)
• If CXR inconclusive or >small effusion > Chest Ultrasound or Chest CT
• Management of effusion:
• If small / simple (< 1cm on lateral decubitus or <1/4 hemithorax): antibiotics only (with uncomplicated pneumonia regimen), with reassessment if failing to improve
• If moderate (>1/4 but <1/2 hemithorax) and with low degree of respiratory compromise
• Per IDSA guidelines, it could be reasonable to consider treatment with antibiotics alone (using complicated pneumonia regimen)
• Also consider chest US and obtaining pleural fluid (thoracentesis or chest tube)
• These patients require close monitoring as their status may change requiring intervention, strongly consider transfer to tertiary center
• If large / loculated (= complicated PNA):
• If at a tertiary center, consult with Infectious Disease and Peds Surgery service
• If at community center, transfer to tertiary center

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Discharge Criteria / Discharge Planning

• Can convert to oral antibiotics when clinically improving
• Choice of PO Antibiotic (usual transition):
• Typical PNA treated with Ampicillin IV = High-dose Amoxicillin
• Typical PNA: Azithromycin
• Influenza PNA: Oseltamivir
• Complicated PNA: Should be guided by Peds ID consult where available and culture results
• Total Duration of Therapy (IV+PO)
• Uncomplicated CAP: 7 days
• Complicated CAP: Duration is individualized, consult with ID recommended
• PMD follow-up: within 2 days of hospital discharge

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Frequently Asked Questions

• Do I need to consider different empiric antibiotics if unimmunized or under-immunized (i.e., incomplete vaccines)?

• No- Immunization status should not affect antimicrobial treatment decisions, based on herd immunity data and current epidemiology, children who are completely unimmunized should not necessarily be treated with broader spectrum therapy especially if their pneumonia is not severe

• What does being unimmunized vs under-immunized or incomplete vaccines mean?

• Unimmunized = no vaccines

• Under-immunized/incomplete vaccines = Not having age-appropriate vaccines

• What about adding azithromycin for atypical CAP when hospitalized?

• Recent studies show no additional benefit is seen when empirically adding atypical PNA coverage for hospitalized pediatric patients. The addition of a macrolide should be reserved when atypical PNA is highly suspected or testing positive for Mycobacteria. (Williams et. al)

• When does one suspect an atypical CAP?

• School aged patient

• Symptoms are variable and include cough, malaise, fever, and occasionally headache

• On physical examination can hear rales within days after onset of constitutional symptoms.

• Cough is initially nonproductive, then can become productive, persist for 3 to 4 weeks, and be accompanied by wheezing

• What if my patient is allergic to a penicillin?

• True penicillin allergic reactions are rare and many patients are mislabeled. It is recommended that providers obtain a thorough history to ascertain the risk of a true allergy.

• UCSF Infectious Disease Management program provides some guidance here: Assessment of Antibiotic Allergies- https://idmp.ucsf.edu/content/assessmentantibiotic-allergies

• Also refer to Kahn, D et al. “Drug allergy: A 2022 practice parameter update” published in the Journal of Allergy and Clinical Immunology

• What PO antibiotic do I convert to if I started Ceftriaxone due to a penicillin/amoxicillin allergy?

• There is now more evidence that indicates there is a lower risk of cross-reactivity to beta lactams than previously thought. If there is a non-anaphylactic allergic reaction to penicillin, it is safe to give any cephalosporin without testing.

• The choice of oral cephalosporin you choose will depend on what you have available locally. Consider spectrum of activity and ideally use the narrowest spectrum available to you.

• A second-generation cephalosporin, (e.g. cefprozil and cefuroxime) is narrower spectrum and a nice alternative to broader spectrum antibiotics (e.g., cefdinir) and provides good coverage against typical CAP pathogens

• What about a Procalcitonin during the diagnostic workup?

• Based on variable availability and limited literature at the time of this guideline creation, we do no routinely recommend a Procalcitonin during the diagnosis work up of a CAP but it can be considered. Some studies have shown that a low procalcitonin is associated with a lower risk of having a typical bacterial infection (i.e., may be viral pneumonia instead) and could support not starting antibiotics. (Stockman et al)

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References

1. 2011 IDSA Guidelines: http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/2011%20CAP%20in%20Children.pdf
2. Esposito S, Tagliabue C, Piccilili I, Semino M, Sabatini C, Conslio S, Bosis S, Pinzani R, Principi N. Procalcitonin measurements for guiding antibiotic treatment in pediatric pneumonia. Respir Med. 2011 Dec;105(12):1939-45. doi: 10.1016/j.rmed.2011.09.003. Epub 2011 Sep 29. PMID: 21959024.
3. Infectious Disease Management Program at UCSF. “Guidelines for Diagnosis and Management of Influenza.” https://idmp.ucsf.edu/content/influenza-0 Accessed 3 November 2021.
4. Infectious Disease Management Program at UCSF. “Community-acquired Pneumonia.” https://idmp.ucsf.edu/content/community-acquired-pneumonia Accessed 21 July 2023.
5. Johnson DP, Lee V, Gourishankar A, Rajbhandari P, Schefft M, Genies M. Things We Do For No Reason™: Routine Blood Culture Acquisition for Children Hospitalized with Community-Acquired Pneumonia. J Hosp Med. 2020 Feb 1;15(2):107-110. doi: 10.12788/jhm.3279. Epub 2019 Sep 18. PMID: 31532737.
6. Khan DA, Banerji A, et al. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunli. 2022 Dec;150(6):1333-1393. doi: 10.1016/j.jaci.2022.08.028. Epub 2022 Sep 17. PMID: 36122788.
7. Moreno et al. “Development and Validation of a Clinical Prediction Rule to Distinguish Bacterial from Viral Pneumonia in Children”. Pediatric Pulmonliogy. 41: 331-337 (2006).
8. Pernica JM, Harman S, Kam AJ, et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021;175(5):475–482. doi:10.1001/jamapediatrics.2020.6735
9. Schondelmeyer AC, Dewan ML, Brady PW, Timmons KM, Cable R, Britto MT, Bonafide CP. Cardiorespiratory and Pulse Oximetry Monitoring in Hospitalized Children: A Delphi Process. Pediatrics. 2020 Aug;146(2):e20193336. doi:10.1542/peds.2019-3336. Epub 2020 Jul 17. PMID: 32680879; PMCID: PMC7397733.
10. Stockmann C, Ampofo K, Killpack J, Williams DJ, Edwards KM, Grijalva CG, Arnlid SR, McCullers JA, Anderson EJ, Wunderink RG, Self WH, Bramley A, Jain S, Pavia AT, Blaschke AJ. Procalcitonin Accurately Identifies Hospitalized Children With Low Risk of Bacterial Community-Acquired Pneumonia. J Pediatric Infect Dis Soc. 2018 Feb 19;7(1):46-53. doi: 10.1093/jpids/piw091. PMID: 28158460; PMCID: PMC6251689.
11. Williams DJ, Edwards KM, Self WH, et al. Effectiveness of Beta-Lactam monotherapy vs macrliide combination therapy for children hospitalized with pneumonia. JAMA Pediatr. 2017;171(12):1184- 1191.

Disclaimer

These clinical practice guidelines are based upon the evidence-based consensus opinions of consortium members affiliated with UCSF Benioff Children's Hospitals. They are intended to guide pediatric/neonatal providers, but do not substitute for individual clinical judgment. Evaluation and treatment of specific patients should be adapted based upon the unique conditions of each patient, family and clinical environment.

 

UCSF Northern California Pediatric Hospital Medicine Consortium. Originated 12/2013. 

Revised 9/2014, 1/2016, 5/2017, 10/2017, 7/2023 

Reviewed by UCSF BCH Antimicrobial Stewardship Program: 5/2022 

Approved by UCSF Pharmacy and Therapeutics Committee: 9/5/2023

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