Thomas M. File, Jr., MD; John S. Bradley, MD


November 02, 2011

This feature requires the newest version of Flash. You can download it here.

The New Pediatric Community-Acquired Pneumonia Guidelines

Thomas M. File, Jr., MD: Hello. I am Tom File, Chair, Infectious Disease Section at Northeast Ohio Medical University. I am here with Dr. John Bradley who is Director, Division of Infectious Diseases at Rady Children's Hospital San Diego. We are at the Infectious Diseases Society of America (IDSA) Annual Meeting here in Boston.

The IDSA has developed numerous guidelines for the management of a variety of infections, but most recently we have published a guideline on the management of community-acquired pneumonia in infants and children.[1] This is somewhat unique because it is one of the few guidelines that focuses directly on the pediatric population. John Bradley is the lead author of this guideline, and he directed the panel. We would like to take just a few minutes to talk together about this new IDSA guideline for community-acquired pneumonia in children.

John S. Bradley, MD: Thanks, Tom.

Dr. File: This guideline is somewhat unique because it focuses just on the pediatric population. Why do we need a specific guideline focused on the pediatric population when we have had guidelines for community-acquired pneumonia in adults for a number of years?

Dr. Bradley: That's a great question, Tom, and as a pediatrician, I am glad that you are asking me about it. We have certainly been interested in working with the adult guidelines and perhaps having a pediatric section, but pneumonia is so different in children that we believed it would be better to have our own specific guidelines. In children, viral pneumonia is far more prevalent than bacterial pneumonia, especially in preschool kids under 2 years of age. Children are immunocompromised. Not only are their immune systems compromised in the first 6 months of life -- that's rather profound -- but up to 2 years of age, and even longer, there is a problem with response to polysaccharide antigens. We are more cautious in taking care of these children.

The other thing that is a little different in caring for children is that everyone who sees children who are having a hard time breathing and have fever and cough wants to give them antibiotics because they don't want to miss a bacterial infection. As a result, most of these kids with viral disease are getting overtreated with antibiotics. So we thought that pediatrics should have its own set of guidelines, and we are very grateful to you for supporting us in our effort.

The Guidelines and the Evidence

Dr. File: John, you have convinced me, and I appreciate the importance of having this new guideline. We know that there was a diversity of members of your panel. Could you review who was on the panel who developed this guideline?

Dr. Bradley: Many people take care of children with pneumonia. Each of us who has a role in treating pneumonia takes a slightly different approach. As lead author on the writing group, my job was to keep them all coordinated and in dialogue to come up with consensus opinions. The group that we put together did that very well. We had general pediatricians, hospitalists, infectious disease physicians, pulmonologists, critical care physicians, and emergency medicine physicians. We had a representative from the US Centers for Disease Control and Prevention (CDC) -- a physician epidemiologist -- and we had a pediatric surgeon.

All of these people together would take a certain question and then we had a chance to share opinions: everyone's view on how to tackle that particular question. In the end, we ran our answers through the committees and with the deliberations, not only with the members but with their professional societies, and we were able to come up with a consensus.

Dr. File: One of the very important aspects of developing clinical practice guidelines is to make them evidence based. How did you evaluate the evidence for this guideline?

Dr. Bradley: As with all the guidelines, we went through the entire literature looking for evidence on making the diagnosis. What is the epidemiology? What is the evidence for treatment? Unfortunately in pediatrics, because people tend to not want to be invasive in sticking needles into chests for a microbiological or viral diagnosis or use a placebo-controlled trial -- in which some children get antibiotics and others, you just watch get sicker with pneumonia -- we have very poor evidence, actually. There are a number of studies; most of them are uncontrolled. Knowing the pathogens that cause pneumonia, precious few studies have done a very good job of culture, and more recently, molecular diagnosis.

I can't say that many of our recommendations were based on strong evidence. But for each point for which we didn't have strong evidence, we took that point and put it into a table at the very end of the guideline, saying that we need studies on this particular issue so that when the next iteration of the guideline comes out, we hope to have good science on which to base our recommendations.

Dr. File: That's very important to help us see what needs to be done in the future to answer some of these questions. It is my understanding that you used the GRADE system, which is a very systematic approach to evaluating the evidence, and that's very important.

Let's go through some of the processes of care recommendations that are in your guidelines. First, how do you make the diagnosis of pneumonia in a child?

Making the Diagnosis of Pneumonia in a Child

Dr. Bradley: We looked at the World Health Organization diagnosis of pneumonia, which is used in the developing world: basically fever, cough, and an increased respiratory rate. Of course, in the developed world we have more medical resources and access to medical care. In trying to diagnose pneumonia, we still are going back to a clinical diagnosis: Is there some level of toxicity? We don't have good validated toxicity scores in children for level of respiratory distress, the way you have for adults.

We have separate recommendations for outpatient management. If the child is not so ill as to require hospitalization, then if you look at the literature on the value of white blood cell counts, sedimentation rates, C-reactive proteins, and chest radiographs, it's fairly poor. We didn't have a lot of evidence to support that kind of evaluation. Most of the diagnostic techniques that give you a viral pathogen are very expensive and PCR [polymerase chain reaction] based, and most offices don't have access to them.

Once the child is in the hospital, the rate of bacteremia begins to go up. The resources for managing those kids and diagnosing pneumonia increases. For children who are hospitalized, we are still recommending some of the very basic tests: the white blood cell count and C-reactive protein. However, we don't have lots of evidence to prove that a high white blood cell count is an accurate test: sensitive, specific, with high positive or negative predictive values. That is an area where we believe diagnostic techniques really need to be honed. We want the pediatrician in the office or in the emergency department to be able to do a test right there and say, "Wow, we know that it is bacterial, or viral, or both."

Treatment: Back to the 1970s?

Dr. File: We would all like that, but, of course, we don't have that right now. Let me go to first-line treatment. What is your recommendation for first-line treatment in these guidelines?

Dr. Bradley: In the past, we used third-generation cephalosporins. Before the pneumococcal conjugate vaccine came out, we were so worried about pneumococcal resistance that some people were even recommending vancomycin in addition to ceftriaxone for every child hospitalized with bacterial pneumonia. With the success of the conjugate vaccine and the documented reduction in penicillin resistance -- even though it started to increase toward the end of the 7-valent vaccine era, we now have a 13-valent vaccine and resistance has gone back down -- presentations at this meeting document this.

You don't need third-generation cephalosporins. Heaven forbid, you certainly don't need vancomycin for pneumococcus. We are recommending for outpatient management, amoxicillin, and for an inpatient management, intravenous ampicillin. We are going back to the 1970s, Tom.

Top 3 Things to Know

Dr. File: In closing, can you summarize for us? There are 92 recommendations in the guidelines, but what would you say are the top 3 things that you would want our viewers to remember from this guideline?

Dr. Bradley: Viral disease is most prevalent, clearly. Pneumococcal resistance is down, so amoxicillin and ampicillin are now the drugs of choice for routine administration. Third, keep up the immunizations, not only Haemophilus influenzae and the pneumococcal vaccine, but also influenza vaccine for every child every year.

Dr. File: I agree with that wholeheartedly. Thank you for listening. This has been Tom File and John Bradley for IDSA and Medscape. Let me just state in closing that this guideline that John just excellently reviewed is available for download at the IDSA Website.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.