Transcript Ppt - American Academy of Pediatrics

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Current Diagnosis & Treatment of
Community-Acquired Pneumonia
in Children
Highlights of the PIDS/IDSA National Guidelines
Samir S. Shah, MD, MSCE, FAAP
Professor, Department of Pediatrics
University of Cincinnati College of Medicine
Director, Division of Hospital Medicine
Cincinnati Children's Hospital Medical Center
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Disclaimers
 Statements and opinions expressed are those of the authors and not
necessarily those of the American Academy of Pediatrics.
 Mead Johnson sponsors programs such as this to give healthcare
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Disclaimers continued
 I have no financial conflicts of interest to disclose.
 I have not received any compensation for preparing and presenting
this webinar.
 I served as Associate Chair of the Pediatric Infectious Diseases
Society/Infectious Diseases Society of America Pneumonia
Guidelines Committee, the topic of this presentation.
 Sources of current research support:
o National Institute of Allergy and Infectious Diseases
o Agency for Healthcare Research and Quality
o Children’s Hospitals Association
o Robert Wood Johnson Foundation
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Objectives
 Discuss the rationale for creating pediatric
community-acquired pneumonia (CAP) national
guidelines.
 Describe currently recommended diagnostic and
treatment strategies for CAP in the United States.
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Why Do We Need Guidelines?
 Role of guidelines
o Assist in healthcare decision-making
o Reduce variation in clinical practice
o Lead to better patient care and outcomes
 Only as good as the evidence on which they are
based
 Most useful for conditions with substantial variation
in clinical practice and outcomes
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Context for the US Guidelines
 CAP is the most common serious childhood infection
in the US.
o 3 million outpatient visits each year
o >150,000 hospitalizations each year
o Up to 15% of children hospitalized with CAP have a serious
pneumonia-associated complication such as empyema.
 In the US, there is substantial variation across
hospitals and physicians in diagnosis, treatment, and
outcomes.
Kronman MP. Pediatrics. 2011; Shah SS. J Hosp Med. 2011; Lee GE. Pediatrics. 2010; Shah SS. Pediatr Pulmonol. 2010
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Diagnostic Testing for CAP at 43 US Hospitals
Brogan TV. Pediatr Infect Dis J. 2012
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Diagnostic Testing for CAP at 43 US Hospitals
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Diagnostic Testing for CAP at 43 US Hospitals
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Treatment for CAP at 43 US Hospitals
Data from Ambroggio LV, et al. Pediatr Infect Dis J. 2012
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Available Free Online and In Print
 Guidelines available at: www.idsociety.org
 Bradley JS, Byington CL, Shah SS, and Alverson B, Carter ER, Harrison C,
Kaplan SL, Mace S, McCracken G, Moore M, St. Peter S, Stockwell J,
Swanson JT. 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. Clin Infect Dis. 2011;53:e25–e76
 Bradley JS, Byington CL, Shah SS, and Alverson B, Carter ER, Harrison C,
Kaplan SL, Mace S, McCracken G, Moore M, St. Peter S, Stockwell J,
Swanson JT. Executive Summary: The management of communityacquired 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. Clin Infect Dis. 2011;53:617–
630
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Consensus Development Based on Evidence
 92 recommendations
 Consensus development based on evidence
o GRADE working group (Grading of Recommendations,
Assessment, Development, and Evaluation)
o Method of assigning strength of recommendation and
quality of evidence to each recommendation
Strength of Recommendation (Strong or Weak)
Quality of Evidence (High, Moderate, or Low)
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Evidence-Based Guidelines
 Clinical Recommendations
o
o
o
o
o
o
o
Site of care
Diagnostic testing
Anti-infective treatment
Adjunctive treatment
Management of the child not responding to treatment
Discharge criteria
Prevention
 Future research
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Evidence-Based Guidelines
 Clinical Recommendations
o
o
o
o
o
o
o
Site of care
Diagnostic testing
Anti-infective treatment
Adjunctive treatment
Management of the child not responding to treatment
Discharge criteria
Prevention
 Future research
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Outline
 Diagnostic Testing
o
o
o
o
o
o
Pulse oximetry
Chest x-ray
Blood culture
Atypical bacteria testing
Viral testing
Complete blood counts
 Anti-Infective Treatment
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Definition of CAP
 CAP is the presence of signs and symptoms of
pneumonia in a previously healthy child due to an
infection acquired outside of the hospital.
 Guideline scope
o Age 3 months – 18 years
o Exclusionary conditions
• Immune deficiency
• Chronic lung disease (e.g., cystic fibrosis)
• Mechanical ventilation
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Diagnostic Testing—Pulse Oximetry
Outpatient and Inpatient
Recommendation
Comments
Recommended
In all children with pneumonia
and suspected hypoxemia.
The presence of hypoxemia
should guide decisions and
further diagnostic testing.
Recommendation Strength
Evidence Quality
Strong
Moderate
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Initial Chest X-Ray—Recommendation
Outpatient
Recommendation
NOT Recommended
Inpatient
Recommended
Recommended
Comments
For confirmation of
Patients with
All patients
suspected CAP in
hypoxemia, significant hospitalized with CAP;
patient well enough to respiratory distress, to document presence,
be treated in
and failed antibiotic
size, and character of
outpatient setting
therapy; to verify
infiltrates and identify
(after evaluation in
presence or absence complications that may
office, clinic, or ED).
of complications.
require interventions.
Strength
Evidence Quality
Strong
Strong
Strong
High
Moderate
Moderate
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Initial Chest X-Ray—Rationale
 Chest x-rays (CXRs) not routinely required for outpatient CAP
 CXRs:
o Do not reliably distinguish bacterial from viral CAP or among the
various bacterial pathogens
o Impractical in office setting
• Often requires travel to a separate facility
• Barriers to physicians obtaining timely results
o CXR in outpatient setting infrequently changes clinical
management
 Guideline provides guidance on when to perform CXR in
outpatient setting
Swingler GH. Cochrane Database Syst Rev. 2008; Swingler GH. Lancet. 1998; Novack V. J Intern Med. 2006; Alario AJ. J Pediatr. 1987;
Grossman LK. Ann Emerg Med. 1988
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Repeat Chest X-Ray—Recommendation
Outpatient AND Inpatient
Recommendation
NOT Recommended
Comments
Not routinely indicated in children
who recover uneventfully
Recommendation Strength
Evidence Quality
Strong
Moderate
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Repeat Chest X-Ray—Recommendation
Outpatient AND Inpatient
Recommendation
Comments
Recommended
Recommended
For inadequate
In children with
clinical improvement,
complicated
progressive
pneumonia with
symptoms, or clinical
worsening
deterioration within respiratory distress
48–72 hours after
or clinical instability
initiation of
antibiotics
Recommended
4–6 weeks after the
diagnosis of CAP in
limited circumstances
(e.g., recurrent
pneumonia in same
lobe or suspicion of an
anatomic anomaly)
Recommendation
Strength
Strong
Strong
Strong
Evidence Quality
Moderate
Low
Moderate
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Repeat Chest X-Ray—Rationale
 Repeat CXRs commonly identify persistent or
residual abnormalities 3–6 weeks later.
o Abnormalities rarely alter management.
o Abnormalities do not predict treatment failure or worse
clinical outcome.
 Repeat CXRs represent unnecessary radiation
exposure to infants and children.
Gibson NA. BMJ. 1993; Virkki R. Pediatr Pulmonol. 2005; Grossman LK. Pediatrics. 1979; Wacogne I. Arch Dis Child. 2003; Heaton P. N Z Med
J. 1998; Bruns AH. Clin Infect Dis. 2007
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Blood Cultures―Recommendations
Recommendation
Outpatient
NOT Recommended Recommended
Inpatient
Recommended
Comments
Strength
Evidence Quality
Non-toxic, fully immunized
children treated as
outpatients
Failure to demonstrate
clinical improvement,
progressive symptoms,
or deterioration after
initiation of antibiotic
therapy
Requiring
hospitalization for
moderate-severe
bacterial CAP
Strong
Strong
Strong
Moderate
Moderate
Low
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Blood Cultures—Rationale
 Outpatient
o Infrequently identifies pathogens (<2%)
o False-positives more common than true positives at some
hospitals
o Rarely informs outpatient management
Bonadio WA. Pediatr Emerg Care. 1988; Hickey RW. Ann Emerg Med. 1996; Shah SS. Arch Pediatr Adolesc Med. 2003; Shah SS. Pediatr Infect
Dis J. 2011
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Blood Cultures—Rationale
 Outpatient
o Infrequently identifies pathogens (<2%)
o False-positives more common than true positives at some
hospitals
o Rarely informs outpatient management
 Inpatient
o
o
o
o
Positive in ~3% of uncomplicated pneumonia
Positive in ~15% with empyema
Allows for culture-directed therapy when positive
Provides local epidemiologic data
Bonadio WA. Pediatr Emerg Care. 1988; Hickey RW. Ann Emerg Med. 1996; Shah SS. Arch Pediatr Adolesc Med. 2003; Shah SS. Pediatr Infect
Dis J. 2011
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Atypical Bacteria Testing―Recommendation
Recommendation
Comments
Strength
Evidence Quality
Mycoplasma
pneumoniae
Recommended
Chlamydophila
pneumoniae
NOT recommended
If signs/symptoms
consistent with but not
classic for Mycoplasma;
can help guide antibiotic
selection.
Reliable and readily
available diagnostic tests
do not currently exist.
Weak
Strong
Moderate
High
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Atypical Bacteria Testing―Rationale
 Evolving understanding of M. pneumoniae
epidemiology
o Increasingly identified in younger children
 Rapid tests (IgM and PCR) available
o Variable test accuracy
o Treatment is not mandatory, especially with low likelihood
of infection (e.g., negative test), as benefit of macrolide
antibiotics uncertain
Heiskanen-Kosma T. Pediatr Infect Dis J. 1998; Michelow IC. Pediatrics. 2004; Korppi M. Respirology. 2004; Thurman KA. Clin Infect Dis. 2009
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Viral Testing―Recommendations
Recommendation
Comments
Strength
Evidence Quality
Influenza
Recommended
Other Respiratory Viruses
Recommended
Use sensitive and specific tests.
Can modify clinical decision
Positive influenza test may
making in children with suspected
decrease the need for additional
pneumonia; antibiotics are not
tests and antibiotic use, while
required in the absence of
guiding the use of antiviral agents
findings that suggest bacterial
in both outpatient and inpatient
co-infection.
settings.
Strong
Weak
High
Low
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Diagnostic Testing—Viral Pathogens
 Antibacterial therapy is not necessary in children,
either outpatients or inpatients, with a positive test
for influenza virus in the absence of clinical,
laboratory, or radiographic findings that suggest
bacterial co-infection.
Strong recommendation; High-quality evidence
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Viral Testing—Rationale
 Influenza testing
o Positive tests reduce antibiotic use and ancillary testing
(e.g., CXR, CBC) by >50%.
o Positive tests guide antiviral treatment decisions.
• Early treatment improves outcomes.
Bonner AB. Pediatrics. 2003; Esposito S. Arch Dis Child. 2003; Iyer SB. Acad Emerg Med. 2006; Benito-Fernandez J. Pediatr Infect Dis J. 2006
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Viral Testing—Recommendations
Recommendation
Comments
Strength
Evidence Quality
Influenza
Recommended
Other Respiratory Viruses
Recommended
Use sensitive and specific tests.
Can modify clinical decision
Positive influenza test may
making in children with suspected
decrease the need for additional
pneumonia; antibiotics are not
tests and antibiotic use, while
required in the absence of
guiding the use of antiviral
findings that suggest bacterial
agents in both outpatient and
co-infection.
inpatient settings.
Strong
Weak
High
Low
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Complete Blood Count—Recommendation
Recommendation
Comments
Strength
Evidence Quality
Outpatient
Inpatient
NOT Recommended
NOT Recommended
However, may provide useful
However, may provide useful
information in those with more information for those with severe
serious disease for clinical
pneumonia; to be interpreted in
management in the context of
the context of clinical exam and
clinical exam and other laboratory
other laboratory and imaging
and imaging studies.
studies.
Weak
Weak
Low
Low
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Complete Blood Count—Rationale
 Anemia and thrombocytopenia may suggest
hemolytic-uremic syndrome.
o Rarely an occult process.
 WBC count has poor specificity for diagnosis of
bacterial pneumonia.
o WBC elevated in many children with CAP.
o Most children with elevated WBC do not have CAP.
o WBC does not reliably distinguish bacterial from viral CAP.
Waters AM. J Pediatr. 2007; Banerjee R. Pediatr Infect Dis J. 2011; Korppi M. Eur Respir J. 1997
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Antibiotic Choice—Outpatient
Age of Child
Recommendation
Comments
Strength
Evidence Quality
Infant / Preschool-Age
School-Age
No antibiotics
Amoxicillin
Amoxicillin
Azithromycin
Antibiotics NOT
routinely
required
because viral
pathogens are
most prevalent.
First-line
therapy if
previously
healthy and
immunized.
First-line
therapy if
previously
healthy and
immunized.
Provides
excellent
coverage for
S. pneumoniae.
Consider
atypical
bacterial
pathogens.
For treatment
of older
children
with findings
compatible
with CAP
caused by
atypical
pathogens.
Strong
Strong
Strong
Weak
High
Moderate
Moderate
Moderate
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Antibiotic Choice—Outpatient Alternatives
Allergy
Amoxicillin
Azithromycin
Alternatives
• 2nd/3rd generation Cephalosporin
• Clindamycin
• Levofloxacin
• Doxycycline (>7 years old)
• Levofloxacin or Moxifloxacin
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Antibiotic Choice—Inpatient
Recommendation
Comments
Strength
Evidence Quality
First Line
Second Line
Ampicillin / PCN G
3rd Generation Cephalosporin
Non-immunized, in regions
with high levels of PCN
resistant pneumococcal strains,
or in children with lifeImmunized infant, preschool,
threatening infection.
or school-age child.
Non-beta lactam agents (e.g.,
vancomycin) are not needed for
the treatment of pneumococcal
pneumonia.
Strong
Weak
Moderate
Weak
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Antibiotic Choice—Inpatient Secondary Agents
Atypical Bacteria
S. aureus
Macrolide
Vancomycin or Clindamycin
In addition to beta-lactam
therapy if atypical bacteria
are significant
considerations. Instead of
beta-lactam if findings are
characteristic of atypical
infection.
In addition to beta-lactam
therapy if clinical,
laboratory, or imaging
characteristics are
consistent with infection
caused by S. aureus.
Recommendation
Strength
Weak
Strong
Evidence Quality
Moderate
Low
Recommendation
Comments
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Antibiotic Choice—Rationale
 S. pneumoniae remains most common bacterial cause of CAP
 Decreasing S. pneumoniae antibiotic resistance
o >50% decrease in penicillin-non-susceptible infections
o >50% decrease strains in resistance to multiple antibiotics
Kyaw MH. N Engl J Med. 2006
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Antibiotic Choice—Rationale
 Penicillin resistance is not associated with treatment
failure for non-CNS S. pneumoniae infections.
o In vitro, bactericidal activity achieved at low concentrations
relative to MIC
o In vivo, high and sustained concentrations achieved in
serum and lung
• Amoxicillin administered at 80 mg/kg/day
• Ampicillin administered at 300 mg/kg/day
Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Perez-Trallero E. J Chemother. 2001
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Antibiotic Choice—Rationale
 Macrolide resistance and 2nd generation cephalosporin
resistance are associated with treatment failure for
non-CNS S. pneumoniae infections.
 Vancomycin
o Not necessary for S. pneumoniae
o MRSA less common and rarely “occult”
o Challenges
 Poor lung penetration compared with aminopenicillins
 Associated with nephrotoxicity
 May require monitoring trough concentrations or continuous infusion
Yu VL. Clin Infect Dis. 2003; Perez-Trallero E. J Antimicrob Chemother. 1998; Chung J. Anaesth Intensive Care. 2011
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Minimizing Resistance―Duration of Therapy
Treatment for the shortest effective duration will minimize exposure
of both pathogens and normal microbiota, and minimize the selection
for resistance.
Strong recommendation; Low-quality evidence
Treatment courses of 10 days have been best studied. Shorter courses
may be just as effective, particularly for more mild disease managed
on an outpatient basis.
Strong recommendation; Moderate-quality evidence
Infections caused by certain pathogens, notably CA-MRSA, may require
longer treatment than those caused by S. pneumoniae.
Strong recommendation; Moderate-quality evidence
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Final Thoughts
Guidelines are only as good as the
evidence on which they are based.
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Final Thoughts
Developing guidelines is relatively easy
compared to implementing them.
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Outpatient Bottom Line
Test
Should I do it?
Comment
Pulse oximetry
Yes
CXR
No
Consider in some circumstances
Repeat CXR
No
Consider in some circumstances
Influenza testing
Yes
During influenza season
Mycoplasma
Yes
Encouraged if considering macrolide
Sputum
No
Blood culture
No
CBC
No
Yes, if deterioration or no improvement
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Outpatient Bottom Line
Role
Antibiotic
Comment
First-Line
Amoxicillin
Alternate
2nd/3rd generation
cephalosporin; clindamycin;
levofloxacin
Alternate
Macrolide
Add to include coverage
for atypicals.
Alternate
Macrolide
Substitute to include
coverage for atypicals if
pneumococcal coverage is
not desired.
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Inpatient Bottom Line
Test
Should I do it?
Comment
Pulse oximetry
Yes
CXR
Yes
Repeat CXR
No
Consider in some circumstances
Influenza testing
Yes
During influenza season
Mycoplasma
Yes
Encouraged if considering macrolide
Sputum
Yes
If child can provide
Blood culture
Yes
CBC
No
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Inpatient Bottom Line
Role
Antibiotic
Comment
First-Line
Ampicillin
Alternate
Cefotaxime or Ceftriaxone
If unimmunized
Alternate
Macrolide
Add to include coverage
for atypicals.
Alternate
Macrolide
Substitute to include
coverage for atypicals if
pneumococcal coverage is
not desired.
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Thank You!
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