What are the clinical practice guidelines (CPG) for managing pediatric community-acquired pneumonia?

Clinical Practice Guidelines for Pediatric Community-Acquired Pneumonia

Diagnostic Approach

Initial Assessment and Pulse Oximetry

Pulse oximetry must be performed in all children with suspected pneumonia to guide site-of-care decisions and determine need for hospitalization. 1 Hypoxemia (SpO2 <90% at sea level) is a critical indicator for hospitalization and further diagnostic workup. 1

Chest Radiography Strategy

• Outpatient setting: Routine chest radiographs are NOT necessary for children well enough to be treated as outpatients. 1 This is a strong recommendation based on high-quality evidence.
• Obtain chest radiographs (PA and lateral) when: 1
  • Hypoxemia is present or suspected
  • Significant respiratory distress exists
  • Initial antibiotic therapy has failed after 48-72 hours
  • Complications are suspected (parapneumonic effusions, necrotizing pneumonia, pneumothorax)
• Inpatient setting: All hospitalized children require chest radiographs (PA and lateral) to document infiltrates and identify complications. 1

Laboratory Testing

Blood Cultures:

• Outpatient: Do NOT obtain blood cultures in nontoxic, fully immunized children managed as outpatients. 1
• Inpatient: Obtain blood cultures in children requiring hospitalization for moderate to severe CAP, particularly with complicated pneumonia. 1

Complete Blood Count:

• NOT routinely necessary for outpatients 1
• Should be obtained for severe pneumonia requiring hospitalization, interpreted alongside clinical and radiographic findings 1

Acute-Phase Reactants (ESR, CRP, Procalcitonin):

• Cannot be used as the sole determinant to distinguish viral from bacterial CAP 1
• NOT routinely needed in fully immunized outpatient children 1
• May provide useful information in hospitalized patients or those with complications to assess response to therapy 1

Viral Testing:

• Rapid influenza testing should be performed, as positive results decrease need for antibiotics and guide antiviral therapy. 1
• Antibacterial therapy is NOT necessary with positive influenza testing in the absence of bacterial coinfection findings. 1
• Testing for other respiratory viruses can modify management by reducing unnecessary antibiotic use. 1

Atypical Pathogen Testing:

• Test for Mycoplasma pneumoniae when signs and symptoms are suspicious to guide antibiotic selection. 1
• Do NOT test for Chlamydophila pneumoniae as reliable diagnostic tests do not exist. 1

Hospitalization Criteria

Children requiring hospitalization include: 1

• Moderate to severe CAP with respiratory distress and hypoxemia (SpO2 <90% at sea level)
• Infants <3-6 months of age with suspected bacterial CAP
• Suspected or documented CA-MRSA pneumonia
• Concerns about home observation, compliance with therapy, or follow-up capability

ICU Admission Criteria

Admit to ICU or continuous cardiorespiratory monitoring unit when: 1

• Invasive mechanical ventilation required
• Noninvasive positive pressure ventilation (CPAP/BiPAP) acutely needed
• Impending respiratory failure present
• SpO2 <92% on FiO2 ≥0.50
• Sustained tachycardia, inadequate blood pressure, or need for vasopressor support
• Altered mental status due to hypercarbia or hypoxemia

Severity criteria include major criteria (invasive ventilation, fluid-refractory shock, acute NIPPV need, hypoxemia requiring high FiO2) and minor criteria (tachypnea per WHO classification, apnea, increased work of breathing, PaO2/FiO2 <250, multilobar infiltrates, PEWS score >6, altered mental status, hypotension, effusion presence, comorbidities, unexplained metabolic acidosis). 1 Consider ICU care with ≥1 major or ≥2 minor criteria. 1

Treatment Approach

Antibiotic Therapy

First-line treatment for hospitalized children is ampicillin-sulbactam (or amoxicillin-clavulanate if oral intake tolerated) plus azithromycin to cover typical bacterial pathogens and atypical organisms. 2 For severe pneumonia requiring IV therapy, co-amoxiclav, cefuroxime, or cefotaxime are appropriate first-line options. 3

• Duration: Minimum 5-7 days of total antibiotic therapy 2, 4
• Transition to oral: After 3 days of IV therapy if clinically improved 2
• Outpatient first-line: Amoxicillin for children under 5 years, effective against majority of CAP pathogens in this age group 3, 4

Oxygen Therapy

Maintain SpO2 >92% at all times. 2, 3 Initiate supplemental oxygen via nasal cannula, head box, or face mask if SpO2 <92% on room air. 2, 3 Transfer to ICU if requiring FiO2 ≥0.50 to maintain SpO2 >92%. 2, 3

Fluid Management

Administer IV fluids at 80% of maintenance levels due to SIADH risk, with daily serum electrolyte monitoring. 2, 3 Avoid nasogastric tubes when possible as they may compromise breathing, especially in infants. 3

Monitoring

• Vital signs (temperature, respiratory rate, heart rate, oxygen saturation) every 4 hours 2
• Continuous pulse oximetry for patients on oxygen therapy 3
• Strict intake/output monitoring and daily weight assessment 2
• Monitor for clinical deterioration including increased work of breathing, recurrent apnea, or worsening mental status 3

Supportive Care

• Acetaminophen for fever management 2
• Gentle nasal suctioning as needed 2
• Elevate head of bed 30-45 degrees 2
• Do NOT perform chest physiotherapy as it is not beneficial 2

Follow-up Imaging

Repeated chest radiographs are NOT routinely required in children recovering uneventfully from CAP. 1 Obtain follow-up radiographs only when: 1

• Clinical improvement fails to occur
• Progressive symptoms or clinical deterioration within 48-72 hours after antibiotic initiation
• Complicated pneumonia with parapneumonic effusion (though routine daily radiographs after chest tube placement are not recommended if clinically stable)

Discharge Criteria

Discharge when the patient meets all of the following: 2

• Afebrile for ≥24 hours
• Oxygen saturation >92% on room air
• Normalized respiratory rate
• Improved work of breathing
• Tolerating oral intake

Key Pitfalls to Avoid

• Do not obtain chest radiographs routinely in well-appearing outpatients—this leads to overdiagnosis and unnecessary antibiotic use 1
• Do not use procalcitonin or CRP alone to distinguish viral from bacterial pneumonia 1
• Do not prescribe antibiotics for influenza-positive patients without evidence of bacterial coinfection 1
• Do not continue antibiotics beyond 5-7 days for uncomplicated CAP 2, 4
• Do not use severity scores as sole criteria for ICU admission—integrate with clinical, laboratory, and radiologic findings 1