Uncomplicated Community Acquired Pneumonia Community Acquired Pneumonia: Infection of airways and lung tissue caused by a multitude of organisms, including a viral and bacterial etiology, which has been acquired outside of the hospital 1 Uncomplicated Pneumonia: Pneumonia in the absence of significant effusion, empyema, severe or impending respiratory failure, and/or signs and symptoms of sepsis or shock

EVALUATION •

Initial Evaluation o General symptoms of pneumonia as well as atypical symptoms o Include all assessment elements pertinent to pneumonia

•

Monitoring o Pulse-oximetry only with vital signs or change in clinical condition o Continuous cardiac/pulse oximetry monitoring reserved for unstable patients and those under 3 months

LABORATORY STUDIES | IMAGING

Only indicated if will change the outcome • Laboratory studies o Complete blood count (CBC) and differential not typically indicated o C-reactive protein (CRP)/Erythrocyte sedimentation rate (ESR) not typically indicated o Viral studies only indicated if results would change treatment o Blood cultures should not be routinely obtained in outpatients or hospitalized children with uncomplicated pneumonia

•

Imaging o Chest x-ray (CXR) not indicated for outpatients o Routinely indicated for inpatients o Repeat CXR only for deterioration or lack of improvement

TREATMENT •

Therapeutics o Children less than 5 years much more likely to be viral o Children requiring hospitalization can be treated with oral antibiotics unless not improving or vomiting/decreased GI absorption o Duration suggested is 5-7 days o Atypical bacteria-testing is not routinely recommended and positive test does not have to be treated o Common complication for those children diagnosed with influenza and more likely to be Staphylococcus aureus o Airway clearance (CPT, VEST, cough assist) not recommended other than gentle activity o EzPAP is not an evidence based therapy o Bronchodilators should not be routinely used

Table 1. World Health Organization Age-Specific Criteria for Tachypnea Table 2. Recommended Nomenclature of Adventitious Breath Sounds Table 3. CAP Antimicrobials – Dosing, Cost, and Implications of Therapy Table 4. Maximum oxygen liter flow for discharge

ALGORITHM. Uncomplicated Community Acquired Pneumonia Antibiotic Treatment Page 1 of 16





TARGET POPULATION Intended for previously healthy patients: 1 • • •

90 days through 21 years of age With signs, symptoms, or other findings suggesting a diagnosis of uncomplicated pneumonia acquired by exposure to organisms in the community. For patients under 90 days of age, reference appropriate clinical care guideline for: o o

Infant Fever: Age less than 28 days Infant Fever: Age 28 to 90 days

Not intended for:

• Patients with complicated pneumonia (i.e. empyema, large effusion) • Immune-compromised host • Medically complicated child • Patients in need of immediate critical care • Systemic illness concerning for sepsis, hospital acquired pneumonia, or illness necessitating ICU admission

KEY TREATMENT PRINCIPLES Indicated: • • •

Clinical Care Guideline use starting in the office or emergency department (ED) Blood cultures for hospitalized patients for presumed bacterial pneumonia that is moderate to severe Ampicillin or amoxicillin as first line antimicrobial

Not indicated: • • • • • •

Complete blood count (CBC)/White blood cell count (WBC) C-Reactive Protein (CRP) Erythrocyte sedimentation rate (ESR) Blood culture Chest physiotherapy (CPT) Albuterol in the absence of asthma

TABLE OF CONTENTS Background | Definitions Initial Evaluation and Monitoring Laboratory Studies | Imaging Clinical Management Therapeutics Algorithm Measures References Clinical Improvement Team

Background | Definitions Community Acquired Pneumonia: Infection of airways and lung tissue caused by a multitude of organisms, including a viral and bacterial etiology, which has been acquired outside of the hospital 1 Uncomplicated Pneumonia: Pneumonia in the absence of significant effusion, empyema, severe or impending respiratory failure, and/or signs and symptoms of sepsis or shock

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Occult pneumonia: the presence of radiographic pneumonia in children who do not show signs of respiratory distress or lower respiratory tract findings on physical examination 2

Initial Evaluation and Monitoring

Clinical Assessment History 1. General symptoms of pneumonia include fever, cough, tachypnea, increased work of breathing, and chest pain 2. Abdominal pain and or vomiting may be a symptom of pneumonia even in the absence of other respiratory symptoms 3. Assessment elements should include: a. Immunization history b. TB exposure including exposure to anyone with a chronic cough c. History of foreign body aspiration risk d. Animal exposure e. Travel history f. Other ill contacts including family members or day care/school exposures Literature review of predictors of Pneumonia/Diagnosis 3 The best individual examination measures for predicting pneumonia in children less than 5 years are: 4 1. Nasal flaring (age less than 12 months) 4 2. Decreased oxygen saturation ** 4,5 3. Tachypnea (see Table 1 for criteria) 5 4. Retractions a. Occult pneumonia has been identified in 6.8% of children who underwent chest radiograph for suspicion of 6 pneumonia . 3 6 b. In children with fever 39.0°C or greater and WBC 20,000/mm or greater, 9% had evidence of occult pneumonia. 7 c. Best negative predictive indicator is absence of tachypnea: negative predictive value (NPV) 88% 4 5. The best combined group of predictors for radiographic pneumonia are: 1. Fever 2. Tachypnea 3. Hypoxemia **This citation is based on patients at elevation lower than Denver, CO. Decreased oxygen saturation at this elevation is typically less than 90% on room air.

7

Table 1. World Health Organization Age-Specific Criteria for Tachypnea Age Approximate normal respiratory rates Tachypnea threshold (breaths/min) (breaths/min) 2 to 12 months 25 to 40 50 1 to 5 years 20 to 30 40 5 years or over 15 to 25 30

Examination 1. Physical findings commonly present with pneumonia a. Crackles (see Table 2) b. Decreased breath sound intensity

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c. Bronchial breath sounds—abnormally loud breath sounds audible throughout the respiratory cycle, resembling sounds normally heard only over large airways d. Absence of these findings doesn’t exclude pneumonia e. Wheezing is usually seen with airway inflammation and less commonly seen with pneumonia but may be present with pneumonia 2. Physical findings commonly present with pneumonia that may be easier to elicit in older children a. Egophony b. Whispered pectoriloquy c. Increased fremitus d. Bronchophony Table 2. Recommended Nomenclature of Adventitious Breath Sounds8 Accepted Nomenclature

Acoustic Characteristic

Associated Pathology

Typical Phase of respiration

Course Crackle

Discontinuous “popping” sound

Inspiration

Fine Crackle

Higher pitched discontinuous “popping” sound

Wheeze

Continuous high pitched “whistling” sound

Rhonchus

Continuous low pitched “snoring” sound

Larger airways popping open associated with edema or inflammation (suggestive of pneumonia) Smaller airways popping open associated with edema or inflammation (suggestive of pneumonia) Small airway constriction (suggestive of asthma, bronchiolitis, or viral pneumonitis) More central airway sound often associated with secretions

Other commonly associated terminology Course rale*

Inspiration

Fine rale* Crepitation

Expiration



Inspiration “coarse breath and/or sound” expiration *discouraging use of the term “rale” per Pulmonary terms and symbols. A report of the ACCP-STS Joint Committee on 9 Pulmonary Nomenclature

Monitoring 1 1. Check pulse oximetry with vital signs or with a change in clinical condition. 2. Continuous cardiac/pulse oximetry monitoring is only recommended for unstable patients and/or for patients under 3 months of age. 3. Patients under 3 months of age; patients who are unstable; and patients who have a history of apnea should have their oxygen titrated to keep SaO2 at or above 90% while on continuous monitoring. Clinical Titration of Oxygen for Stable Infants over 3 Months of Age 1. If respiratory rate is less than 50 bpm, minimal retractions, and child is active and feeding well: wean oxygen flow in increments of 0.125 to 0.5 Lpm. Assess for titration of oxygen at least every 4 hours. 2. If respiratory rate is rapid for age, infant has significant retractions or nasal flaring, or infant is feeding poorly: increase oxygen incrementally. Consider continuous pulse oximetry if oxygen flow is greater than 1 Lpm for infants 3 to 6 months of age or greater than 2 Lpm for children older than 6 months.





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Laboratory Studies | Imaging

Diagnostic Tests and Studies: Diagnostic tests are only indicated if they will change outcome. Radiologic Studies 1. Chest x-ray (CXR) is not routinely indicated in patients well enough to be treated as outpatients 10-12 2. Traditionally, diagnosis of pneumonia relies on positive radiographic findings 1 3. CXR should be performed in hospitalized patients with suspected pneumonia. 2-view CXR is encouraged to: a. Establish diagnosis of pneumonia b. Evaluate for foreign body c. Promote judicious use of antibiotics d. Direct appropriate therapy 1 4. Repeat CXR is only indicated for clinical deterioration or lack of clinical improvement . 5. If child has recurrent pneumonia (defined as 3 times in lifetime or 2 times within 6 months), consider repeat CXR in 4 to 6 weeks1 after clinical resolution to confirm radiographic resolution.

Laboratory studies 1.

2.

3. 4. 5.

6.

CBC a. CBC and differential should not be obtained unless adjunctive information is necessary to help decide whether to use antibiotics13-15 • Note: CBC has a limited role, and is often not useful, in differentiating between viral and bacterial pneumonia 16,17 ° b. In young children (less than age 5), presenting with fever without source (temperature 39 C or greater), significant leukocytosis (WBC 20,000/mm3 or greater) may be predictive of radiographic pneumonia (9% have radiographic evidence of pneumonia)6 CRP/ESR a. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and other measures of acute phase reactants should not be performed, as these tests are not specific enough to be useful13,14,16,18,19 b. ESR and procalcitonin have a limited role in differentiating viral from bacterial pneumonia, and the sensitivity of CRP is too poor to be clinically useful.1,16,17 Note: CBC/ESR/CRP may be used to help monitor response in patients who aren’t typically improving with initial therapy or those who present with systemic illness concerning for sepsis (this population is excluded in this CCG). Viral Studies a. Viral testing is indicated if results would change management Testing for atypical bacteria (see additional considerations for atypical bacteria below) Sputum a. Consider Gram stain and culture on high quality specimens when managing children capable of producing an adequate sample (typically school age)1,20. • Note: A high quality sputum is usually defined by the presence of less than 10 squamous epithelial cells and greater than 25 WBCs per low power field20 Tuberculin Skin Testing (TST) a. TST or IGRA should be conducted in children with a history of exposure to tuberculosis, chronic cough, personal or family travel in areas where tuberculosis is prevalent, per RedBook recommendations.21



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TB isolation precautions and notification of epidemiology is required if TB is strongly suspected or confirmed. See http://prdplanetcf02.thechildrenshospital.org/policiesfitz/general/pdf/487.pdf 7. Blood Cultures 1,22,23 a. Blood cultures should not be routinely obtained in outpatients Note: When pneumonia is diagnosed in an outpatient setting, the likelihood of a positive blood culture is less than 2.7%23 b. Blood cultures are not recommended for hospitalized children with presumed moderate to severe bacterial pneumonia (bacteremia risk 0-6%)24,25, but should be strongly considered for children with complicated pneumonia.1 c. If child is well appearing and reliable follow-up can be assured, discharge to home should not be delayed for final results of blood culture. 8. Urinary Antigen Detection Tests a. Urinary antigen detection tests are not recommended for the diagnosis of pneumococcal pneumonia in children1 9. Other a. When historical, physical, radiologic, or laboratory findings are inconsistent, additional studies should be considered to evaluate for alternative or coincident conditions, such as foreign body aspiration or immunodeficiency. b. Consider pertussis PCR for patients when predominant clinical component is cough (as opposed to pneumonia), particularly if paroxysmal, or prolonged, or diagnosis supported epidemiologically b.

Clinical Management Prevention 1. Hand hygiene 2. Isolation procedures 3. Influenza and pneumococcal vaccine protocols

Therapeutics (Refer to Algorithm and Table 3) 1.

In children less than 5 years of age, etiology is much more likely to be viral and routine use of antibiotics is not recommended (viral causes include Influenza A and B, Respiratory syncytial virus, Parainfluenza viruses, Human metapneumovirus, Adenovirus, and Rhinovirus)

2.

Common bacterial causes of pneumonia in childhood include the following: o Streptococcus pneumoniae o Staphyloccocus aureus (including MRSA) o Haemophilus influenza (if under-immunized) o Group A streptococcus o Atypical pathogens (Bordetella pertussis, Mycoplasma pneumoniae – school age children, Chlamydophila pneumoniae – school age children)

3.

Route of treatment: o According to PIDSA Guidelines1, “Children with suspected bacterial CAP that is serious enough to warrant hospitalization should routinely be treated with parenteral antibiotics to provide reliable blood and tissue concentrations.” Therefore, IV antibiotics for initial therapy should be considered in patients with uncomplicated CAP admitted to the hospital with vomiting or suspected decreased GI absorption.

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For patients with mild illness, initial therapy with oral antibiotics may be appropriate. Failure of outpatient oral therapy is defined as fever greater than or equal to (≥)38.0°C lasting greater than or equal to (≥) 48 hours 26, and may be due to inadequate choice or dosing of antibiotic, poor compliance, natural history of disease, or resistant organism. It is still reasonable to treat intravenously with narrow choice (ampicillin, good coverage for most Streptococcus pneumoniae and 70% of Haemophilus influenzae), as pharmacokinetics far superior to oral amoxicillin or cephalosporins. Other choices should be used if gram negatives suspected, or Staphylococcus aureus suspected (see Table 3) 2729 . 4. Duration of treatment: o Duration of antimicrobial therapy is suggested to be 5-7 days for non-severe CAP 30,31. o If child fails to improve within 48 to 72 hours of initiation of treatment, consider alternate diagnosis or therapy 1. 5. Modification of treatment: o Should specific pathogen identification become available, tailor antibiotic therapy based on microbiology results o o

Additional considerations for the treatment of Mycoplasma pneumoniae (and other atypical pathogens): 1. Azithromycin cannot be used to treat Streptococcus pneumoniae pneumonia, so should only be considered “if atypical suspected” AND Streptococcus pneumoniae is not suspected. No clear definition of atypical pneumonia exists, however it is often interpreted as pneumonia in school-aged children with more diffuse abnormal breath sounds, and/or chest x-ray, or those who have failed initial treatment for Streptococcus pneumoniae. On occasion, mycoplasma can cause a lobar pneumonia, but this is not a usual finding. 2.

The literature is limited and not clear that there is benefit to treating Mycoplasma pneumoniae lower tract infection. o A multi-center retrospective database cohort study of children hospitalized with Mycoplasma pneumoniae reported empiric use of macrolide therapy was associated with a shorter hospital length of stay (median 3 days in treated patients compared to 4 days in un-treated patients) 32. o Systematic reviews conclude that the available literature does not support or refute treatment of lower respiratory tract infection due to Mycoplasma pneumonia 33-35.

3.

The CHCO rapid pathogen panel (RPP) tests for both mycoplasma pneumoniae and chlamydophila pneumoniae; routine testing is not recommended, but testing is indicated if results will change management (i.e. will lead to: targeted treatment of mycoplasma, discontinued treatment for mycoplasma, discontinued treatment for traditional CAP organisms, or no treatment at all).

4.

In the absence of a clear benefit of macrolide therapy and the potential of adverse drug events, testing and treatment for Mycoplasma pneumoniae is not routinely recommended. Children with a negative test should not be treated, children with a positive test do not have to be treated.

5.

The CHCO rapid pathogen panel (RPP) tests for both mycoplasma pneumoniae and chlamydophila pneumoniae; routine testing is not recommended, but testing is indicated if results will change management (i.e. will lead to: targeted treatment of mycoplasma, discontinued treatment for mycoplasma, discontinued treatment for traditional CAP organisms, or no treatment at all).



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Pneumonia in the setting of influenza: 1. Pneumonia is a common complication in children hospitalized with influenza. a. In one study, 27% of children hospitalized with laboratory confirmed influenza had radiologically confirmed pneumonia. Children aged 6 months to 4 years and those with underlying asthma were more likely to have pneumonia. Staphylococcus aureus was the most commonly identified bacterial co-infection in children with influenza-associated pneumonia36. 2. Children hospitalized with influenza co-infected with S. aureus have higher rates of severe outcomes (ICU admission, death)37. 3. It may be difficult to differentiate primary viral (influenza) pneumonia from secondary bacterial pneumonia. Indicators of bacterial superinfection may include: secondary fever after a period of defervescence, lobar consolidation, increased WBC, and later onset (4 to 7 days) of respiratory compromise after initial symptoms38. 4. Empiric coverage for S. aureus infection in children hospitalized with influenza-associated pneumonia should be considered. Other Therapies 1. Therapies directed towards airway clearance (CPT, VEST, cough assist) should not be used for patients with uncomplicated pneumonia 39,40; there are some studies that suggest it can be harmful to some patient 41. 42 a. Chest physiotherapy does not decrease length of stay in children hospitalized with pneumonia . b. Gentle activity should be encouraged as the best way to mobilize secretions. In infants repositioning is considered a form of gentle activity 43. c. Bronchodilators should not be routinely used unless there is known component of asthma. Wheezing that is typically heard in a patient with pneumonia is most likely related to airway inflammation 43. d. There is no evidence-based literature to support the use of intermittent positive pressure therapy (EzPAP) in pediatrics with pneumonia.

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Algorithm. Uncomplicated CAP Antibiotic Treatment a





a

: Patients with complicated pneumonia (i.e. empyema, large effusion), immunocompromised patients, patients in need of immediate critical care, and those patients with concern for sepsis do NOT fall under this treatment algorithm. b : This is intended for uncomplicated cases only. See Table 3 for dosing recommendations, cost comparisons, and other implications of therapy. c : Assess whether the patient has had 2 or more doses of the H. influenzae type B (HiB) vaccine and consider the risk for invasive H. influenzae B disease based on the vaccine coverage in your community (herd protection). d : Amoxicillin component should be dosed at 90mg/kg/day divided TID if concerned for S. pneumoniae or other isolates with higher MICs (including H. influenzae and S. aureus). If using 90mg/kg/day divided TID dosing, use high dose formulation (Amox/Clav ES Suspension – 600mg/5mL – 42.9mg/5mL or Amox/Clav 875mg-125mg tablets). e : Oral cephalosporin formulations are considered pharmacologically inferior to amoxicillin, particularly for non-susceptible S. pneumoniae. If used, it should be used in highest dose and shortest interval allowable. See Table 3. f : Amoxicillin is the drug of choice for bacterial CAP due to its favorable pharmacokinetics against S. pneumoniae susceptible and intermediate strains (when dosed 90mg/kg/day divided TID). g : Alternatives to azithromycin for treatment of atypical pathogens include clarithromycin, erythromycin, or if patient is older than 7 years: doxycycline. See text regarding Mycoplasma pneumoniae, Bordetella pertussis, and Chlamydophila pneumoniae reporting off of the standard RPP.





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Table 3: CAP Antimicrobials – Dosing, Cost, and Implications of Therapy

Antibiotic

Recommended Dose

Amoxicillin (PO)

Amoxicillin/ Clavulanate (PO)

PREFERRED: 90mg/kg/day divided TID (max: 3,000mg/day) OTHER: 90mg/kg/day divided BIDb

**Take note of appropriate formulation choice** PREFERRED: 90mg/kg/day divided TID (max: 3,000mg/day if using suspension and 2,625mg/day if using tablet) OTHER: 90mg/kg/day divided BIDb

Costa $45 (liquid more expensive)

$88 generic (liquid more expensive)

• See comments for amoxicillin • Amoxicillin/clavulanate adds some gram negative, MSSA, and anaerobic coverage and should be reserved for patients in which expanded coverage is desirable (i.e. under-immunized) • It is recommended that total daily dose of clavulanate remain below 10mg/kg/day to mitigate GI side effects • Ratio of amoxicillin and clavulanate components vary, so not all formulations can be used for “high” or “low” dosing. o Formulations for “high” dosing (90mg/kg/day) § Amoxicillin-clavulanate ES suspension 600-42.9mg/5mL § Amoxicillin-clavulanate 875-125mg tablets (be aware of max clavulanate dosing) o Formulations for “low” dosing (45mg/kg/day) § Amoxicillin-clavulanate suspension 400-57mg/5mL § Amoxicillin-clavulanate 500-125mg tablets § Amoxicillin-clavulanate 200-28.5mg chewable tablets

Ampicillin (IV)

200mg/kg/day divided q6h (max: 8,000mg/day)

--

Ampicillin/ Sulbactam (IV)

200mg/kg/day divided q6h (max: 8,000mg/day)

--

Cefotaxime (IV)

150mg/kg/day divided q8h (max: 6,000mg/day)

Cefpodoxime (PO)c

Cefprozil (PO)

c

Ceftriaxone (IV)

Cefuroxime axetil (PO)

10mg/kg/day divided BID (max: 800mg/day)

30mg/kg/day divided BID (max: 1.000mg/day)

50mg/kg/day q24h (max: 2,000mg/day)

30mg/kg/day divided BID (max: 1,000mg/day)

Implications of Therapy • 90mg/kg/day divided TID is the best choice for susceptible and intermediate S. pneumoniae in order to achieve adequate time above the MIC. o Other regimens acceptable for susceptible, but not intermediate, S. pneumoniae. o Only 75% of S. pneumoniae at Children’s Colorado are fully susceptible • 90mg/kg/day divided TID is also encouraged for other bacterial organisms implicated in CAP with higher MICs, including H. influenzae and S. aureus.

--

• Preferred intravenous antibiotic for initial treatment • Can be used for penicillin-allergic patients • If a PO transition is warranted, it is recommended that either amoxicillin or amoxicillin-clavulanate be prescribed given the unfavorable pharmacokinetic profile of oral cephalosporins in the treatment of CAP.

$143 (brand)

• Can be used as an alternative for PCN allergic patients; however, cephalosporin formulations are considered to pharmacologically inferior to amoxicillin, particularly for non-susceptible S. pneumoniae. • Has relatively poor oral absorption and higher protein binding compared to amoxicillin, making it more difficult to treat non-susceptible S. pneumoniae.

$174

• Can be used as an alternative for PCN allergic patients; however, cephalosporin formulations are considered to pharmacologically inferior to amoxicillin, particularly for non-susceptible S. pneumoniae. • Has relatively poor oral absorption and higher protein binding compared to amoxicillin

--

• Can be used for penicillin-allergic patients • If a PO transition is warranted, it is recommended that either amoxicillin or amoxicillin-clavulanate be prescribed given the unfavorable pharmacokinetic profile of oral cephalosporins in the treatment of CAP.

$440 (brand)

• Can be used as an alternative for PCN allergic patients; however, cephalosporin formulations are considered to pharmacologically inferior to amoxicillin, particularly for non-susceptible S. pneumoniae. • Has relatively poor oral absorption and higher protein binding compared to amoxicillin

Azithromycin (IV or PO)

10mg/kg/day 1st day, followed by 5mg/kg/day (max: 500mg/day)

$43

• ONLY indicated for coverage of atypical pneumonias as 40% of CHCO S. pneumoniae isolates are predicted to be resistant. • If an RPP is ordered and Mycoplasma pneumoniae is not detected, it is strongly encouraged to discontinue azithromycin therapy.

Clindamycin (IV or PO)

30-40mg/kg/day divided TID (max PO: 1,800mg/day, max IV: 2,700mg/day)

$360

• 27% of our S. pneumoniae is resistant • 14% of our S. aureus is resistant

a

: Cost based on 20kg child x 10 days, purchased from Walgreen’s pharmacy suspension formulation in Colorado for cash-paying customers during third quarter of 2014. b : Twice daily dosing may be considered for outpatient use if compliance is a concern. c : Non-formulary agent at CHCO. May be used if prescribing to an outpatient and insurance coverage warrants.

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Measures Measures Length of stay Antibiotic choice st (Amox or Amp 1 choice) Route of antibiotic (oral preferred)

Location IP IP ED/UC IP ED/UC

TCH Target TBD TBD TBD TBD TBD



Parent | Caregiver Education

Pneumonia (English version) Pneumonia (Spanish version) Home Oxygen Therapy (English version) Home Oxygen Therapy (Spanish version)

Admission | Discharge Criteria

Admission 1 1. Critical care • Respiratory failure or impending respiratory failure [hypercapnia, acidosis, supplemental O2 need greater than 50% FiO2, severe dehydration, altered mental status, ventilation (invasive or noninvasive) with need for increased support, underlying neuromuscular issues, or compromised ability to handle secretions or maintain airway] • Sustained tachycardia, hypotension, or need for pharmacologic support of blood pressure or perfusion 2. Inpatient setting; one or more of the following • Cannot take antibiotics orally • Dehydration requiring IV fluids • Hypoxemia • Concern or risk for progressive or complicated pneumonia 3. Discharge home •

Oxygen requirements: See Table 4

Table 4. Maximum oxygen liter flow for discharge

•

• •

Age of Patient:

Maximum liter flow for discharge:

Less than 24 months and stable

½ liter per minute or less

Older than 24 months and stable

1 liter per minute or less

Stable and improving hypoxemia and improving clinical status, patients may be discharged home on O2 after 24 hours or more of observation and treatment. These clinical care guidelines are designed to assist clinicians and patients make decisions about appropriate care of the patient with uncomplicated community acquired pneumonia and are not meant as a substitute for sound clinical judgment. Reliable follow up and social situation Clinical status: • Respiratory rate approaching normal as expected for age • Normal work of breathing • Able to maintain hydration orally • Baseline mental status

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4. Medications • Able to take medications orally • Able to obtain prescription to complete course Follow up 1. Establish PCP follow up within 2 to 3 days





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References 1. 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 : an official publication of the Infectious Diseases Society of America 2011;53:e25-76. 2. Shah S, Mathews B, Neuman MI, Bachur R. Detection of occult pneumonia in a pediatric emergency department. Pediatric emergency care 2010;26:615-21. 3. Ebell M. Clinical diagnosis of pneumonia in children. Am Fam Physician 2010;82:192-3. 4. Mahabee-Gittens EM, Grupp-Phelan J, Brody AS, et al. Identifying children with pneumonia in the emergency department. Clinical pediatrics 2005;44:427-35. 5. Harari M, Shann F, Spooner V, Meisner S, Carney M, de Campo J. Clinical signs of pneumonia in children. Lancet (London, England) 1991;338:928-30. 6. Rutman MS, Bachur R, Harper MB. Radiographic pneumonia in young, highly febrile children with leukocytosis before and after universal conjugate pneumococcal vaccination. Pediatric emergency care 2009;25:1-7. 7. Shah S, Bachur R, Kim D, Neuman MI. Lack of predictive value of tachypnea in the diagnosis of pneumonia in children. The Pediatric infectious disease journal 2010;29:406-9. 8. Murphy RL. In defense of the stethoscope. Respiratory care 2008;53:355-69. 9. n.a. Pulmonary terms and symbols. A report of the ACCP-STS Joint Committee on Pulmonary Nomenclature. Chest 1975;67:583-93. 10. Redd SC, Patrick E, Vreuls R, Metsing M, Moteetee M. Comparison of the clinical and radiographic diagnosis of paediatric pneumonia. Transactions of the Royal Society of Tropical Medicine and Hygiene 1994;88:307-10. 11. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of communityacquired pneumonia in adults. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2007;44 Suppl 2:S27-72. 12. McIntosh K. Community-acquired pneumonia in children. The New England journal of medicine 2002;346:429-37. 13. Korppi M. Non-specific host response markers in the differentiation between pneumococcal and viral pneumonia: what is the most accurate combination? Pediatrics international : official journal of the Japan Pediatric Society 2004;46:545-50. 14. Toikka P, Irjala K, Juven T, et al. Serum procalcitonin, C-reactive protein and interleukin-6 for distinguishing bacterial and viral pneumonia in children. The Pediatric infectious disease journal 2000;19:598-602. 15. Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Annals of emergency medicine 1999;33:166-73. 16. Virkki R, Juven T, Rikalainen H, Svedstrom E, Mertsola J, Ruuskanen O. Differentiation of bacterial and viral pneumonia in children. Thorax 2002;57:438-41. 17. Don M, Valent F, Korppi M, Canciani M. Differentiation of bacterial and viral communityacquired pneumonia in children. Pediatrics international : official journal of the Japan Pediatric Society 2009;51:91-6. Page 13 of 16

18. Heiskanen-Kosma T, Korppi M. Serum C-reactive protein cannot differentiate bacterial and viral aetiology of community-acquired pneumonia in children in primary healthcare settings. Scandinavian journal of infectious diseases 2000;32:399-402. 19. Ruuskanen O, Mertsola J. Childhood community-acquired pneumonia. Seminars in respiratory infections 1999;14:163-72. 20. Skerrett SJ. Diagnostic testing for community-acquired pneumonia. Clinics in chest medicine 1999;20:531-48. 21. Alves dos Santos JW, Torres A, Michel GT, et al. Non-infectious and unusual infectious mimics of community-acquired pneumonia. Respiratory medicine 2004;98:488-94. 22. Claesson BA, Trollfors B, Brolin I, et al. Etiology of community-acquired pneumonia in children based on antibody responses to bacterial and viral antigens. The Pediatric infectious disease journal 1989;8:856-62. 23. Hickey RW, Bowman MJ, Smith GA. Utility of blood cultures in pediatric patients found to have pneumonia in the emergency department. Annals of emergency medicine 1996;27:721-5. 24. Murtagh Kurowski E, Shah SS, Thomson J, et al. Improvement methodology increases guideline recommended blood cultures in children with pneumonia. Pediatrics 2015;135:e1052-9. 25. Heine D, Cochran C, Moore M, Titus MO, Andrews AL. The prevalence of bacteremia in pediatric patients with community-acquired pneumonia: guidelines to reduce the frequency of obtaining blood cultures. Hospital pediatrics 2013;3:92-6. 26. Lahti E, Peltola V, Virkki R, Ruuskanen O. Influenza pneumonia. The Pediatric infectious disease journal 2006;25:160-4. 27. Queen MA, Myers AL, Hall M, et al. Comparative effectiveness of empiric antibiotics for community-acquired pneumonia. Pediatrics 2014;133:e23-9. 28. Thomas NM, Brook I. Otitis media: an update on current pharmacotherapy and future perspectives. Expert opinion on pharmacotherapy 2014;15:1069-83. 29. Williams DJ, Edwards KM, Self WH, et al. Antibiotic Choice for Children Hospitalized With Pneumonia and Adherence to National Guidelines. Pediatrics 2015;136:44-52. 30. Greenberg D, Givon-Lavi N, Sadaka Y, Ben-Shimol S, Bar-Ziv J, Dagan R. Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: a doubleblind, randomized, placebo-controlled trial. The Pediatric infectious disease journal 2014;33:13642. 31. Esposito S, Cohen R, Domingo JD, et al. Antibiotic therapy for pediatric community-acquired pneumonia: do we know when, what and for how long to treat? The Pediatric infectious disease journal 2012;31:e78-85. 32. Shah SS, Test M, Sheffler-Collins S, Weiss AK, Hall M. Macrolide therapy and outcomes in a multicenter cohort of children hospitalized with Mycoplasma pneumoniae pneumonia. Journal of hospital medicine 2012;7:311-7. 33. Biondi E, McCulloh R, Alverson B, Klein A, Dixon A, Ralston S. Treatment of mycoplasma pneumonia: a systematic review. Pediatrics 2014;133:1081-90. 34. Robenshtok E, Shefet D, Gafter-Gvili A, Paul M, Vidal L, Leibovici L. Empiric antibiotic coverage of atypical pathogens for community acquired pneumonia in hospitalized adults. The Cochrane database of systematic reviews 2008:Cd004418. Page 14 of 16

35. Gardiner SJ, Gavranich JB, Chang AB. Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pneumoniae in children. The Cochrane database of systematic reviews 2015;1:Cd004875. 36. Dawood FS, Fiore A, Kamimoto L, et al. Influenza-associated pneumonia in children hospitalized with laboratory-confirmed influenza, 2003-2008. The Pediatric infectious disease journal 2010;29:585-90. 37. Reed C, Kallen AJ, Patton M, et al. Infection with community-onset Staphylococcus aureus and influenza virus in hospitalized children. The Pediatric infectious disease journal 2009;28:572-6. 38. Wright PF, Kirkland KB, Modlin JF. When to consider the use of antibiotics in the treatment of 2009 H1N1 influenza-associated pneumonia. The New England journal of medicine 2009;361:e112. 39. Hardy KA. A review of airway clearance: new techniques indications and recommendations. Respiratory Care 1994;39:440. 40. De Boeck K, Vermeulen F, Vreys M, Moens M, Proesmans M. Airway clearance techniques to treat acute respiratory disorders in previously healthy children: where is the evidence? European journal of pediatrics 2008;167:607-12. 41. Selsby DS. Chest physiotherapy. BMJ (Clinical research ed) 1989;298:541-2. 42. Paludo C, Zhang L, Lincho CS, Lemos DV, Real GG, Bergamin JA. Chest physical therapy for children hospitalised with acute pneumonia: a randomised controlled trial. Thorax 2008;63:791-4. 43. Pediatric pneumonia treatment & management. n.d. (Accessed March 17, 2010, at http://emedicine.medscape.com/article/967822-treatment#aw2aab6b6b4.)



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CLINICAL IMPROVEMENT TEAM MEMBERS Jenny Reese, MD | Hospital Medicine| [email protected] Leigh Anne Bakel, MD | Hospital Medicine | [email protected] L. Barry Seltz, MD | Hospital Medicine | [email protected] Sarah Parker, MD | Infectious Disease | [email protected] Oren Kupfer, MD | Pulmonary Medicine| [email protected] Amanda Hurst, PharmD | Clinical Pharmacist | [email protected] Jason Child, PharmD | Clinical Pharmacist | [email protected] Aimee Bernard, PhD | Clinical Care Guideline Coordinator | [email protected]

APPROVED BY

Guideline and Measures Review Committee – date here Medication Safety Committee – date here or not applicable Antimicrobial Stewardship Committee – date here or not applicable Pharmacy & Therapeutics Committee – date here MANUAL/DEPARTMENT ORIGINATION DATE LAST DATE OF REVIEW OR REVISION

APPROVED BY

Clinical Care Guidelines/Quality May 5, 2015 March 2, 2016 Lalit Bajaj, MD, MPH Medical Director, Clinical Effectiveness



REVIEW/REVISION SCHEDULE Scheduled for full review on March 3, 2019

Note: Clinical care guidelines are recommendations designed to assist clinicians and patients make appropriate healthcare decisions for specific clinical circumstances and optimal patient outcomes based on the best available evidence, and to identify and track relevant and meaningful measures related to guideline directed care. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment regarding care of a particular patient must be made by the clinician in light of the individual circumstances presented by the patient and the needs and resources particular to the locality or institution.



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