Clinical Practice Guidelines in the Evaluation and Management of PCAP

Clinical Practice Guidelines in the Evaluation and Management of Pediatric Community Acquired PneumoniaREGINA M. CANONIZADO,MD Pediatric Pulmonologist DISEASE BURDEN 150.7m cases in developing countries 95% under 5y/o 13% requiring admission Rudan,2004 828.8 per 100,00 in the Philippines DOH Field Health Svc IS,2006 PhP 324.688M total payment claims PHIC 2006 Goal The guideline is designed to help make decisions concerning the recognition of community acquired pneumonia in the immunocompetent patient aged 3months to 19 years, identification of appropriate and practical diagnostic procedure, and initiation of rational management. For ages 3 months to 5 years : tachypnea and/or chest indrawing (grade B) 2. tachypnea and crackles (Grade D) .Who shall be considered as having communitycommunity-acquired pneumonia? Predictors of community acquired pneumonia in a patient with cough 1. For ages 5 to 12 years: fever. tachypnea and tachycardia and. rhonchi. Beyond 12 years of age: the presence of the following features (Grade D) fever. b. At least one abnormal chest finding of diminished breath sounds.3. crackles or wheezes a. . WHO age specific criteria for tachypnea AGE 2-12 mos 1-5 years >5 years RR >50 >40 >30 . A patient who is at minimal to low risk can be managed on an outpatient basis (Grade D) . A patient who is at moderate to high risk to develop pneumonia ±related mortality should be admitted (Grade D) 2.Who will require admission? 1. Compliant caregiver 3. Ability to follow-up 4. Age 7. Respiratory rate 2-12 months 1-5 years > 5 years > 50/min > 40/min > 30/min > 50/min > 40/min > 30/min > 60/min > 50/min > 35/min > 70/min > 50/min > 35/min . Ability to feed 6. Presence of Dehydration 5. Co-morbid illness 2.Risk Classification for PneumoniaPneumoniaRelated Mortality Variables PCAP A Minimal Risk None Yes Possible None Able >11 mo PCAP B Low Risk Present Yes Possible Mild Able >11 mo PCAP C Moderate Risk Present No Not possible Moderate Unable < 11 mo PCAP D High Risk Present No Not possible Severe Unable < 11 mo 1. Complications (effusion ./stuporous/ comatose Present 9. e.8. Signs of respiratory failure a. pneumothorax) None None Present ACTION PLAN OPD follow-up at the end of treatment OPD followup after 3 days Admit to regular ward Admit to a critical care unit Refer to specialist . d. c. b. Head Bobbing Cyanosis Grunting Apnea Sensorium None None None None Awake None None None None Awake Supraclavicular /Intercostal/ Subcostal Present Present Present Present lethargic. Retraction None None Intercostal/ Subcostal Present Present None None Irritable a. What diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B being managed in an ambulatory setting? No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting (Grade D) . Chest x-ray PA lateral (Grade B) b. Culture and sensitivity of Blood for PCAP D (Grade D) Pleural fluid (Grade D) Tracheal aspirate upon initial intubation (Grade D) Blood gas and/or pulse oximetry (Grade D) . White blood cell count (Grade C) c. The following should be routinely requested : a.What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D being managed in a hospital setting? 1. C-reactive protein (Grade A) . The following may be requested : Culture and Sensitivity of sputum for older children (Grade D) 3.2. Erythrocyte sedimentation rate(Grade A) b. The following should not be routinely requested : a. For a patient classified as either PCAP A or B and is a. Beyond 2 years of age (Grade B) or b.When is antibiotic recommended? An antibiotic is recommended 1. Having high grade fever without wheeze (Grade D) . Having alveolar consolidation in the chest xray (Grade B) or d. Having white blood cell count > 15. 000 (grade C) 3. Beyond 2 years of age (Grade B ) or b.2. For a patient classified as PCAP D (Grade D) . For a patient classified as PCAP C and is a. Having high grade fever without wheeze (grade D) or c. FEATURES Fever Wheeze BACTERIAL T> 38.5o C Present .5o C Absent VIRAL T< 38. oral amoxicillin ( 40-50 mg/kg/ay in 3 divided doses) is the drug of choice (Grade D) .What empiric treatment should be administered if a bacterial etiology is strongly considered? 1. For a patient classified as PCAP A or B without previous antibiotic. For a patient classified as PCAP C without previous antibiotic and who has completed the primary immunization against Haemophilus influenza type b. 000 units/kg/day in 4 divided doses) is the drug of choice (Grade D) . Penicillin G (100.2. a specialist should be consulted (Grade D) .If a primary immunization against Hib has not been completed. For a patient classified as PCAP D. intravenous ampicillin (100 mg/kg/day in 4 divided doses) should be given (Grade D) 3. 8 mg/kg/day for 3-5 days) may be given for influenza that is either confirmed by laboratory (Grade B) or occurring as an outbreak (Grade D) .4-8. Oseltamivir (2 mg/kg/dose BID for 5 days) or amantadine (4. Ancillary treatment should only be given (Grade D) 2.What treatment should be initially given if a viral etiology is strongly considered? 1. Decrease in respiratory signs (particularly tachypnea ) and defervescence within 72 hours after initiation of antibiotic are predictors of favorable therapeutic response (Grade D) .When can a patient be considered as responding to the current antibiotic? 1. 2. ESR or CRP should not be done to assess therapeutic response to antibiotic (Grade D) . Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation (Grade B) 3. WBC. End of treatment chest x-ray (Grade B). What should be done if a patient is not responding to current antibiotic therapy ? 1. If an outpatient classified either PCAP A and PCAP B is not responding to the current antibiotic within 72 hours. Start an oral macrolide. consider any one of the following (Grade D) a. Reevaluate diagnosis . Change of initial antibiotic. or c. or b. or b.2. Presence of complications (pulmonary or extrapulmonary ). If an inpatient classified as PCAP C is not responding to the current antibiotic within 72 hours. penicillin resistant Streptococcus pneumoniae. Other diagnosis . or c. consider consultation with a specialist because of the following possibilities (Grade D) a. consider immediate reconsultation with a specialist (Grade D) .3. If an inpatient classified as PCAP D is not responding to the current antibiotic within 72 hours. Is able to feed with intact gastrointestinal absorption.When can switch therapy in bacterial pneumonia be started? Switch from intravenous antibiotic administration to oral form 2-3 days after initiation of antibiotic is recommended in a patient (Grade D) who a. Is responding to the initial antibiotic therapy . and c. b. Does not have any pulmonary or extrapulmonary complications . chest physiotherapy. topical solution. bronchodilators and herbal medicines are not routinely given in community-acquired pneumonia (Grade D) 3. Cough preparations. nebulization using normal saline solutions. oxygen and hydration should be given if needed (Grade D) 2. Among inpatients. bronchial hygiene. In the presence of wheezing. steam inhalation.What ancillary treatment can be given? 1. a bronchodilator may be administered (Grade D) . Vaccines recommended by the Philippine pediatric Society should be routinely administered to prevent pneumonia (Grade B ) .How can pneumonia be prevented? 1. Zinc supplementation (10 mg for infants and 20 mg for children beyond two years of age given for a total of 4 to 6 months ) may be administered to prevent pneumonia(Grade A) 3.2. Vitamin A (Grade A) . immunomodulators (Grade D) and vitamin C (Grade D) should not be routinely administered as a preventive strategy . Malnutrition ‡ Malnourished children have a significantly higher risk of developing pneumonia compared to well nourished children .Special Considerations 1. ‡ Strep pneumoniae and Hemophulus influenzae should be considered as the most probable cause of pneumonia. ‡ Infection with TB and gram negative enteric bacilli should be considered in non responsive patients . TUBERCULOSIS ‡ No available studies on CAP in children with TB ‡ A child with TB can be malnourished therefore presumed to be immunocompromised . ‡ Usual community acquired pathogens are considered the most probable cause of pneumonia ‡ In patients with extensive pulmonary parenchymal damage secondary to PTB . there is predisposition to infection with anaerobic organisms and Staph aureus . Congenital Heart Disease ‡ CHD with either large volume left to right shunt or chamber enlargement increases the risk of CAP Chest xray studies helpful Viral infections are the most frequent etiologies ‡ ‡ . Principles of therapy ‡ Antiviral agent should be given if a viral pathogen is being considered ‡ Empiric antibiotic therapy should be given if a bacterial pathogen is considered ‡ Observe cautious hydration ‡ Provide oxygenation ‡ Inhaled B2 agonists if with good response . ASTHMA Chlamydia pneumoniae has been associated with persistent type of asthma but not with acute exacerbations. 55% of asthmatics are colonized with atypical organisms in their airways ‡ Use of antibiotic in early childhood is associated with an increased risk of developing asthma and allergic disorders among those predisposed to atopic immune response . ‡ Viral URTI with atelectasis secondary to mucus plug because of asthma is often misdiagnosed as pneumonia ‡ In children without an apparent pneumonia. asthma is the most common cause of recurrent or persistent infiltrate on chest xray . Committee on CPGS are intended to GUIDE practitioners in the detection (and management) of pediatric patients with the disease of interest. .DISCLAIMER The recommendations contained in the document of the PPS.Inc.In no way should the recommendations be regarded as absolute rules. the recommendations should supplement. and NOT replace.since nuances and peculiarities in individual cases or particular communities may entail differences in the specific approach.In the end. sound clinical judgment made on a case to case basis. Hope you learned something today. .