SAN FRANCISCO — Community-acquired pneumonia
remains a significant concern for pediatricians, yet no national
recommendations exist for diagnosis, treatment and prevention of the disease.
Forthcoming guidelines that will address these issues, however, are in
development and publication is expected in 2011.
Carrie L. Byington, MD, HA and Edna Bennington
Presidential Professor of Pediatrics at the University of Utah in Salt Lake
City and vice chair of the AAP’s Committee on Infectious Diseases,
discussed the diagnosis, treatment and prevention of pediatric
community-acquired pneumonia as well as the process of
developing guidelines during a presentation here at the 2010 American Academy
of Pediatrics National Conference and Exhibition.
For children who appear well enough for outpatient
treatment, Byington suggested that pediatricians focus more on the physical
exam instead of outside diagnostic procedures, although obtaining chest
radiographs and X-rays would be appropriate for:
- Children whom a physician intends to admit to a hospital..
- Children with hypoxia or significant respiratory distress.
- Children who are unresponsive to antimicrobial therapy.
- Children suspected of having pleural effusion empyema.
Pediatricians may suspect empyema in patients who have a
fever that persists for 4 or 5 days or a fever that reappears after apparent
resolution. Chest and abdominal pain are also potential indicators of the
condition, according to Byington, as are use of ibuprofen, azythromycin or
single-dose IM ceftriaxone without improvement.
Recent history of varicella or influenza is also
associated with complications of community-acquired pneumonia, highlighting the
importance of vaccination, she said.
Other modes of diagnostic testing, such as obtaining a
complete blood count, are not necessary in the outpatient setting, although
they are indicated for children with hypoxia or those children that are likely
to be admitted to the hospital.
Additionally, C-reactive protein testing is unreliable
in distinguishing between bacterial and viral disease, and therefore may not be
helpful in diagnosing community-acquired pneumonia. Procalcitonin is more
predictive of bacteremic pneumonia, but these tests are less available and
considerably more expensive.
Nontoxic, immunized patients who will receive
outpatient treatment also do not warrant blood cultures because of the high
likelihood for false positives, according to Byington, but inpatients with
evidence of empyema may benefit from these tests.
Byington also noted high false positive rates of urinary
antigen testing for Streptococcus pneumoniae in children. Antigen
testing of pleural fluid, however, may help identify pathogens in cases of
Viral testing also has merit, Byington said, such as
rapid diagnosis of influenza and respiratory syncytial virus. These tests can
easily be performed in inpatient and outpatient settings, and the results allow
for early antiviral treatment; decreases in the use of antibiotics; the
identification of children at high risk for hospital admission; and cohorting
of patients who are admitted to inpatient facilities.
Byington recommended amoxicillin as an appropriate
antibiotic treatment for preschool- and school-aged children with
community-acquired pneumonia in outpatient settings. She also identified
clindamycin as an alternative for penicillin-allergic children. Usual treatment
courses last for approximately 10 days, with dosing depending on the
susceptibility of S. pneumoniae.
Drug treatment for complicated cases is the same,
according to Byington, although a longer course, lasting approximately 2 to 4
weeks, with ampicillin is preferred for penicillin-susceptible S.
Drainage of pleural fluid in cases of community-acquired
pneumonia is appropriate for all effusions that are classified as moderate or
large, with the choice of drainage technique depending on local expertise, said
In accordance with AAP guidelines, palivizumab should be
administered to high-risk infants, said Byington. Immunization with the
influenza vaccine, the Haemophilus influenzae type B vaccine and the
13-valent pneumococcal conjugate vaccine are also important in preventing
Byington said the Infectious Disease Society of America
and the Pediatric Infectious Disease Society are currently collaborating to
create evidence-based recommendations for the national guidelines. - by
For more information:
Byington CL. F1044. Presented at:
2010 AAP National
Conference and Exhibition; Oct. 2-5, 2010; San Francisco