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New Clinical Guidelines Pneumonia

For this update, we are covering the recently released Pneumonia clinical guidelines, emphasizing the recommendations pertinent to ED practice. Note the age covered by the guidelines: they are for pneumonia patients older than 3 months – these guidelines are not applicable to children younger than 3 months.

Some of the recommendations may be surprising, e.g. that the majority of preschoolers with clinically-diagnosed community-acquired pneumonia do not require antibiotics since most have a viral infection. However, remember that these are only guidelines, and clinicians must treat each patient as an individual. 
 
Bradley JS, Byington CL, Shah SS, et al: The Management of Community-Acquired Pneumonia in Infants and Children Older than 3 months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases 2011;53(7):e25-e76.
 
Who should be hospitalized?
1. Respiratory distress of O2 sat < 90% at sea level
2. Suspected bacterial community-acquired pneumonia (CAP) in < 3-6 mo old
3. Suspected virulent pathogen eg MRSA
4. Poor follow-up or unable to comply with therapy
 
Who should be admitted to an ICU?
Obvious: artificial ventilation, NIPPV, impending respiratory failure, shock
Also: O2 sat < 92% on FiO2 > 0.50, altered mental status
 
When should blood cultures be obtained?
Obtain if fail to demonstrate improvement with antibiotics, or deterioration
Obtain in hospitalized with moderate to severe CAP, especially if complicated
 
When should chest radiographs be obtained?
Routine chest radiographs are not necessary to confirm suspected CAP in patients well enough to be treated as an outpatient. Obtain if hospitalized, respiratory distress, hypoxemia, suspected bacterial CAP not improving on antibiotics after 48-72 hours.
 
When and what antibiotics should be given?
Antimicrobial therapy is not routinely required for preschool-aged children with CAP, because viral pathogens are responsible for the great majority of clinical disease.
 
Outpatient therapy: If suspect CAP to be bacterial (not explicitly stated in guidelines, but: high fever, inadequate immunizations, tachypnea, hypoxemia, toxic appearance), Amoxicillin is first-line therapy, macrolide antibiotics if suspect atypical pneumonia. Treatment courses of 10 days most common.
 
Inpatient therapy: Ampicillin or penicillin G for fully immunized patient, third-generation cephalosporin (ceftriaxone or cefotaxime) if not fully immunized, geographic region with high penicillin resistance, empyema. Add macrolide antibiotic if suspect atypical pneumonia. Give vancomycin or clindamycin if suspect infection with S. Aureus

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