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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

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

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 rapid influenza and other respiratory viral testing in the evaluation of children with CAP

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

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

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. In order to maximize the utility of these guidelines for our local patient population, the recommendations do in some places differ from the "weak" Infectious Disease Society of America (IDSA) or other nationally published guidelines based on local practice

Metrics Plan

To be determined.

Authors

D. Chan, M. Chan, K. Hoffman, T. Ruel, R. Wattier, E. Laves, J. Shih, G. Landman.

UCSF Northern California Pediatric Hospital Medicine Consortium. Originated 12/2013. Revised 9/2014, 1/2016. 5/2017. 10/2017.
Approved by UCSF Antimicrobial Subcommittee: 11/2017
Approved by UCSF Pharmacy and Therapeutics Committee: 12/13/2017
Approved b UCSF Quality Improvement Executive Committee: 12/19/2017

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Consensus Clinical Guidelines

 

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

  • Age >3 months and 

  • Absence of chronic lung disease, immunodeficiency, or other congenital anomalies / chronic medical condition predisposing to unusual or recurrent infection

  • 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.

 

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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)

    •  < 6 mo old infants with suspected BACTERIAL CAP likely to benefit from admission

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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

      • Indications for BCx on admission to inpatient setting:

        • "Moderate to severe" CAP:

          • hypoxia

          • increased work of breathing

          • "toxic" or "sick" appearance

      • Balancing factors:

        • (-) risk of contaminants

        • (-) low yield

        • (+ / -) potential change in management

        • (+) opportunity to identify organism pre-antibiotic therapy

    • Viral testing

      • Outpatient:

        • Influenza testing ROUTINELY recommended in patients with influenza-like illness at high risk of influenza complications: Patients 

          • Please refer to yearly CDC guidelines for recommendations about treatment with anti-virals

        • RSV testing: consider RSV testing for children < 3 yrs with consistent symptoms, especially if a positive result would lead to avoidance of antibiotic therapy

      • Recommendations for testing upon admission to inpatient setting:

        • Flu testing indicated during influenza season; flu testing may need to be repeated with more sensitive method if initially done in rapid/office setting (POCT office/ED-based test not as sensitive)

          • Empiric antiviral therapy is recommended for influenza if patient admitted during influenza season with compatible signs/symptoms, until influenza is ruled out by adequately sensitive test

        • RSV testing indicated during RSV season in patients 

        • Serum testing for Mycoplasma pneumonia NOT routinely indicated for suspected atypical infections

        • Sputum sampling NOT routinely indicated

    • Pulse Oximetry Monitoring:

      • Indications for continuous pulse oximetry monitoring:

        • Initial assessment (for period of 4hrs)

        • Unstable clinical status

        • Supplemental oxygen (for period of at least 24hrs)

      • Indications for spot 02 sat checks with periodic vital signs:

        • Clinically stable patient for >24hrs

        • Patients not requiring supplemental oxygen

 

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Antimicrobial Therapy 

  • NOTE: Children with suspected or confirmed viral PNA should generally NOT be treated with antibiotics

  • NOTE: Institutional antibiogram susceptibilities may not be applicable for CAP because susceptibility data is drawn from patient population with higher acuity disease / more invasive disease processes

  • NOTE: Immunization status may affect antimicrobial treatment decisions, but 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

    • Consider consultation with ID if concurrent bacteremia, potentially immunocompromised, or more severe pneumonia

Table 1: EMPIRIC ANTIBACTERIAL THERAPY FOR PEDIATRIC CAP

Diagnosis of Effusion & Adjunctive Therapy

  • Considerations if pneumonia is failing to improve:

  1. Reconsider 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 (

    • 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

  • Choice of PO Antibiotic (usual transition):

    • Typical PNA treated with Ampicillin IV: High-dose Amoxicillin

    • Typical PNA treated with Ceftriaxone IV or Ampicillin-Sulbactam IV: High-dose Amoxicillin-Clavulanate (generally preferred over cefdinir due to poor bioavailability of cefdinir or cefixime)( *See antibiotic table for dosing recommendations)

    • Atypical PNA: Azithromycin

    • Influenza PNA: Oseltamivir

    • Complicated PNA: Should be guided by ID consult

  • Total Duration of Therapy (IV+PO)

    • Uncomplicated CAP: 7-10 days

    • Complicated CAP: Duration is individualized, consult with ID recommended

  • PMD follow-up: within 2 days of hospital discharge

UCSF Northern California Pediatric Hospital Medicine Consortium. Originated 12/2013. Revised 9/2014, 1/2016. 5/2017. 10/2017.
Approved by UCSF Antimicrobial Subcommittee: 11/2017
Approved by UCSF Pharmacy and Therapeutics Committee: 12/13/2017
Approved b UCSF Quality Improvement Executive Committee: 12/19/2017

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References

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Additional Links

USNews Pediatrics 21-22

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