Guidelines for the Management of Pediatric Pneumonia
Abstract & Commentary
Synopsis: A task force of Canadian pediatric infectious disease experts has developed a useful set of guidelines for the diagnosis and management of community-acquired pediatric pneumonia.
Source: Jadavji T, et al. A practical guide for the diagnosis and treatment of pediatric pneumonia. Can Med Assoc J 1997;156:S703-711.
Jadavji and colleagues represent the pediatric infectious diseases divisions of major teaching institutions throughout Canada. They reviewed the knowledge base of pediatric pneumonia and summarized the epidemiology of pneumonia in different age groups of children (infant and toddler, preschool, and school-aged) and the microbiology of pediatric pneumonia, and they assessed the literature on the sensitivity and specificity of various diagnostic methods and evaluated specific therapy in each age group.
Table 1
Age-specific causes of pneumonia in otherwise healthy children
Age Group Pathogen (in order of frequency)
1-3 months Pneumonitis syndrome, usually afebrile: Chlamydia trachomatis, respiratory syncytial virus (RSV), other respiratory viruses, Bordetella pertussis. 1-24 months Mild to moderate pneumonia, RSV, other respiratory viruses, S. pneumonia, H. influenza type B (HiB), Nontypable H. influenza (NTHI), C. trachomatis, Mycoplasma pneumoniae.
2-5 years Respiratory viruses: S. pneumoniae, HiB, NTHI, M. pneumoniae, Chlamydia pneumoniae.
6-18 years M. pneumoniae, S. pneumoniae, C. pneumoniae, NTHI, influenza A or B, adenovirus, other respiratory viruses . All ages Severe pneumonia requiring admission to ICU: S. pneumoniae, Staphylococcus aureus, group A streptococcus, HiB, M. pneumoniae, adenovirus, RSV infants younger than 2 years.
Age is the best predictor of the cause of pediatric pneumonia, with viral pneumonia being most common in the first two years of life. Thereafter, a variety of infectious organisms are seen. (See Table 1.)
The absence of a cluster of respiratory distress, tachypnea, crackles, and decreased breath sounds accurately exclude the presence of pneumonia. Diagnostic tests are of varying benefit. (See Table 2.)
Table 2
Diagnostic tests in children with suspected pneumonia*
Test Physician’s Office ED Hospital
Chest X-ray ++ ++ ++
CBC + + ++
Blood Culture NR + ++
Gram stain and culture sputum + + +
Throat culture NR NR NR
Serological test for Mycoplasma NR NR NR
* ++ strongly recommended
+ recommended
Oral antimicrobial therapy will provide adequate coverage for most mild and moderate forms of pneumonia in children. Parenteral therapy is reserved for neonates and patients admitted to the hospital for severe pneumonia.
COMMENT BY ROBERT BALTIMORE, MD, FAAP
I am one of those who still cringe when I hear the words "guidelines" and "pathway," even though I have worked on some myself. When a group of experts gets together, there is real danger of convoluted pathways, awkward recommendations, and sometimes such a lack of authority that it’s hard to figure out what is recommended. In this case, however, the result is a clear, concise, and useful overview of pediatric pneumonia.
Jadavji et al rate various diagnostic tests such as chest radiograph (strongly recommended); gram staining and culture of sputum in children older than 6 years with a cough (recommended); and culture of a throat swab (not recommended). Their recommendations are thoughtfully broken down for the site of the evaluation (physician’s office, ED, or hospital). Simple treatment options are broken down by age group and then as to whether the patients are outpatients, hospitalized, or in an ICU. Recommended antibiotics are erythromycin, clarithromycin, cefuroxime, and ampicillin/amoxicillin, and this pharmacopoeia is sufficient for all ages and all occasions.
Outpatient recommendations are simple. For neonates up to 3 months of age, no outpatient antibiotic therapy is recommended since hospitalization is routinely indicated; for children ages 3 months to 5 years, amoxicillin or erythromycin or clarithromycin; for children ages 5-18 years, erythromycin or clarithromycin. Indications for hospitalization, in which one of these drugs with or without cefuroxime is recommended in most cases, include: age less than 6 months, toxic appearance, severe respiratory distress, oxygen requirement, dehydration, vomiting, no response to previous oral therapy, and noncompliant parents. Nosocomial pneumonia and pneumonia in immunocompromised children are not covered.
In 1993, The American Thoracic Society published similar guidelines for community-acquired pneumonia.1 Outpatient treatment was almost as simple as the pediatric recommendations in these Canadian guidelines.
The Canadian group should be congratulated for producing a complete, clear, and usable set of guidelines. Its recommendations are useful for the vast majority of children although there may be special circumstances where deviations may be appropriate. It should be re-emphasized that these recommendations are for uncomplicated community-acquired pneumonia. (Dr. Baltimore is Professor of Pediatrics and Epidemiology and Public Health, Yale University School of Medicine.)
Reference
1. Neiderman MS, et al. Am Rev Respir Dis 1993;148: 1418-1426.
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