A first-ever clinical guideline for the management of community-acquired pneumonia (CAP) in older infants and children was released by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America earlier this year.
Recognizing the considerable variation in disease course in these children, the guideline spells out reasons to consider hospitalization, recommended diagnostic testing, and anti-infective therapy for both inpatients and out patients including agent selection, duration of therapy, and strategies to minimize resistance. Moderate to severe CAP is defined as hypoxemia (sustained saturation of peripheral oxygen [SpO2], < 90 % at sea level) and respiratory distress. These infants and those in whom infection with a highly virulent strain is suspected should be hospitalized. Blood cultures, complete blood counts, and measurement of acute phase reactants are not routinely recommended for nontoxic, fully immunized children.
Other key findings:
Severity of illness should not be the sole determinant when considering hospitalization including admission to ICU.
A pending or, even, positive blood culture should not preclude discharge for a child who is clearly improving provided continued therapy and close follow-up is assured.
It is not necessary to confirm suspected CAP with a chest x-ray in children well enough to be managed as outpatients nor are radiographs required for children who recover uneventfully.
Influenza antiviral therapy should be started as soon as possible in children with moderate to severe CAP suspected to be the result of influenza during peak seasons.
Antibiotics should not be routinely used for preschoolers with CAP since viral pathogens cause the great majority of clinical disease in this age group. When antibiotics are used, amoxicillin is first line for healthy, appropriately immunized infants and preschoolers. While 10-day courses have been the most studied, shorter courses may be just as effective for mild CAP.
Therapy for more severely ill children, including those with parapneumonic effusion, is discussed in detail.
Why Is This a Game Changer?
Russell W. Steele, MD, Clinical Professor in the Department of Pediatrics at Tulane University School of Medicine and Division Head of Pediatric Infectious Diseases at Ochsner Children's Health Center reviewed the CAP guidelines for Medscape, noting that guidelines are not meant to establish a standard of practice but rather to offer the clinician a skeletal framework from which to make decisions. In contrast to many other guidelines, there was a striking paucity of good evidence-based medicine available to this expert panel to offer meaningful recommendations. Many of the 92 recommendations are listed as "strong recommendation" but with "low-quality or moderate-quality evidence." This means that there were serious flaws in published studies but the expert panel felt that desirable effects outweighed undesirable effects, or vice versa. Thus we are often left with opinion rather than data in managing infants and young children with CAP. Dr. Steele noted that, while he agreed with most of the recommendations in the document, he did disagree with others. Specifically he cited concerns with:
Recommendation 23: Steele would suggest strengthening the recommendation to test all adolescents for Mycoplasma pneumoniae with bedside cold agglutinins.
Recommendations 41-45: Steele argues that the incidence of bacterial infection in pre-school aged children with CAP is high enough to warrant routine antimicrobial therapy in the outpatient setting. He suggests that macrolides should be added to beta-lactam antibiotics in older children with moderate disease.
"Differences of opinion are healthy. Clinicians can certainly deviate from these recommendations until we have higher quality evidence to change our minds. Meanwhile this expert panel has done an excellent job in providing a skeletal framework for managing CAP in infants and children today" he concluded.
Medscape Pediatrics © 2011 WebMD, LLC
Cite this: Laurie E. Scudder. Game Changers in Pediatrics 2011 - Medscape - Nov 23, 2011.