Pediatric Guidelines for Community-acquired Pneumonia (CAP)

Highlights of the much-anticipated Pediatric Infectious Disease Society/Infectious Disease Society of America (PIDS/IDSA) "Guidelines for the Management of Community-acquired Pneumonia (CAP) in Children and Infants Older than Three Months" were presented during the 48th annual meeting of the IDSA in Vancouver.

John Bradley, MD, FIDSA, Director, Division of Infectious Diseases, Rady Children's Hospital, San Diego, University of California, San Diego, presented the guidelines, but emphasized that they are a draft version and have not received final approval from all the groups collaborating on the guidelines, so changes may still occur.

That said, the scope of the guidelines is comprehensive, covering site of care, diagnostic testing, anti-infective treatment, adjunctive surgical therapy, discharge criteria and prevention. Among the recommendations presented for “Site of Care Management Decisions” was guidance, based on best available evidence, as to when pediatric patients with CAP should be hospitalized. The draft guidelines recommend hospitalization for children and infants as young as 3-6 months of age with moderate to severe CAP. However, this recommendation is still under discussion, Bradley said.

A number of recommendations regarding criteria for admitting a child with CAP to the intensive care unit (ICU) have also been drafted, with particular care paid to both medical and legal implications, Bradley said.

The appropriate use of diagnostic laboratory and imaging tests in suspected cases of pediatric CAP is addressed in the “Diagnostic Testing for Pediatric CAP” section of the draft guidelines. They state that routine measurements of the complete blood count (CBC) is not felt to be necessary in all children with suspected pneumonia managed in the outpatient setting, but for those with more serious disease a CBC may provide useful information. Further, a CBC should be obtained for patients with severe pneumonia, to be interpreted in the context of the clinical exam and other appropriate tests. Additionally, acute phase reactants cannot be used as the sole determinant to distinguish between viral and bacterial causes of CAP.

With respect to anti-infective treatment, Bradley said that “We are in a new era... 10-15 years ago, pneumococcal resistance was rampant. Now, with the success of the conjugate pneumococcal vaccines, we have pulled back to amoxicillin.” The draft guidelines state that "amoxicillin should be used as first-line empiric therapy for previously healthy, appropriately immunized infants and pre-school aged children with mild to moderate CAP suspected to be of bacterial origin." Guidelines regarding ampicillin or penicillin G have also been developed, as has guidance on empiric therapy with a third-generation parenteral cephalosporin.

The guidelines also address antibiotic use as part of adjunctive surgical therapy in pediatric CAP patients with small parapneumonic effusions. The recommendations state that the effusions should not be routinely drained, and can be treated with antibiotic therapy alone. However, patients with moderate effusions and respiratory distress, large parapneumonic effusions, or documented purulent effusions should be drained. In fact, an algorithm has been developed for the management of pneumonia with parapneumonic effusion, as part of the guidelines.

In closing his presentation, Bradley emphasized the need for continued and future research in pediatric CAP, a need that was made clear in the drafting of the guidelines, as he said that there was a paucity of high-quality evidence for many of the recommendations.