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Starship Children’s Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.

PNEUMONIA

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Introduction Clinical features Causative Organisms Investigations Treatment Admission Follow-up

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Recurrent pneumonia or persistent symptoms Complications Prevention: Environment & underlying conditions References

Introduction
These guidelines may not be appropriate for the immunocompromised child or a child with chronic lung disease (e.g. cystic fibrosis, bronchiectasis, neonatal chronic lung disease). Pneumonia, bronchiolitis and asthma are all common illnesses that result in children presenting with acute lower respiratory symptoms and signs. Antibiotics should be given to children with bacterial pneumonia but not to children with bronchiolitis or asthma. The New Zealand population has high rates of pneumonia, complicated pneumonia and long term sequelae (eg bronchiectasis). Pneumonia is more common and more severe in younger children. In Auckland the hospitalisation rate of those < 2 years is 11 times higher than those aged ≥ 4.

Clinical Features
Most children with pneumonia present with cough or difficulty breathing, but only the minority of children with these symptoms have pneumonia. Bacterial pneumonia should be considered in children <3 years of age who present with fever > 38.5, chest recession and increased respiratory rate >50 breaths/minute. Older children with bacterial pneumonia often present with difficultly breathing in combination with tachypnoea. If wheeze is present in a preschool child, primary bacterial pneumonia is unlikely however in school age children it may suggest Mycoplasma pneumoniae (see below). Tachypnoea is a key clinical sign Tachypnoea by age (World Health Organisation) < 2 months age > 60 breaths per minute 2- 12 months age > 50 breaths per minute 12 months to 5 years age > 40 breaths per minute If chest indrawing, nasal flaring, grunting or crepitations are also present then the probability of pneumonia is increased further. Atypical presentations without obvious respiratory symptoms are not rare (abdominal pain and vomiting mimicking an acute abdomen, meningism mimicking meningitis).

Author: Editor: Pneumonia

Drs Best, Brabyn, Shepherd & Twiss Dr Raewyn Gavin Page:

Services: Date Reviewed: 1 of 8

CED, Respiratory, ID, Gen Paeds August 2010

A chest x-ray may be indicated if: • Presentation is atypical • There is diagnostic uncertainty • Infants <3 months of age • Child who is severely unwell • Child has a history suggesting underlying respiratory disease • Complications (such as effusion) are suspected (based on clinical signs or not making anticipated clinical progress). headache or arthralgia. Radiology does not reliably distinguish bacterial from viral pneumonia so does not determine the need for antibiotics. Mixed bacterial and viral infection can occur in up to 40%. Shepherd & Twiss Dr Raewyn Gavin Page: Services: Date Reviewed: 2 of 8 CED. Please remember to read our disclaimer. human metapneumovirus. Table 1: Aetiology of Pneumonia by Age Group in Developed Countries* Age group 0 to 1 months Predominant organisms** Group B streptococcus Gram negative organisms Chlamydia trachomatis Listeria monocytogenes 1 to 24 Respiratory syncytial virus (RSV) and other viruses † Streptococcus pneumoniae months Haemophilus influenzae (non typeable) Bordetella pertussis 2 to 5 years Respiratory syncytial viruses (RSV) and other viruses † Streptococcus pneumoniae Haemophilus influenzae (non typeable) Mycoplasma pneumoniae 6 to 18 years Chlamydia pneumoniae Streptococcus pneumoniae accounts for up to 30% Respiratory viruses account for < 15% of episodes * The proportion of pneumonia due to bacteria increases with age and within each age group likelihood of bacterial infection increases with increasing severity. Mycoplasma pneumoniae should be suspected in school age children especially if the onset of symptoms is insidious and/or the child has wheeze. Any printed version can not be assumed to be current. Likely causative organisms by age group are shown in Table 1. † Other respiratory viruses = Influenza A and B. PNEUMONIA Causative Organisms In developed countries the aetiology of community acquired pneumonia has been defined by the child’s age as well as the severity of the episode of illness.Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. ID. ** Staphylococcus aureus is an important pathogen of serious pneumonia to remember in all age groups Investigations Many children with pneumonia may be diagnosed and managed on clinical grounds alone. adenoviruses. Respiratory. Cold agglutinins and serial mycoplasma serology may be helpful in confirming mycoplasma but seldom influence management decisions so aren’t routinely recommended. human coronavirus. parainfluenzae 1-3 . Author: Editor: Pneumonia Drs Best. Brabyn. Gen Paeds August 2010 .

Mycoplasma pneumonia suspected Antibiotic High dose amoxycillin High dose amoxycillin Erythromycin. In contrast to pneumococcal meningitis.5mg/kg/dose QID 7-10 days 5-7 days Duration 5-7 days OR. maximum 500mg/dose 30 mg/kg/dose TDS* Maximum 1000mg/dose 12. Author: Editor: Pneumonia Drs Best. for diagnosis of suspected viral pneumonia (< 2years) and deciding who may benefit from antiviral medication such as oseltamavir. A blood culture is an insensitive test for bacterial pneumonia in children however blood cultures should be considered in the unwell child with pneumonia. Roxithromycin 4mg/kg. Antibiotics do not prevent pneumonia in children with upper respiratory tract infections. Fever magnitude. respiratory infections with pneumococci with reduced susceptibility to penicillin have not been shown to have worse outcomes and decreased susceptibility can be overcome with the use of high oral or IV dosing of penicillin. Brabyn. PNEUMONIA Sputum. Please remember to read our disclaimer. Dose 30 mg/kg/dose TDS*. This may include some of those requiring admission. throat swabs and NPA for bacterial cultures do not help determine who should receive antibiotics. 1. Treatment Children suspected with bacterial pneumonia should be treated with antibiotics. Shepherd & Twiss Dr Raewyn Gavin Page: Services: Date Reviewed: 3 of 8 CED. Age 3 months to 5 years ≥ 5 years ≥ 5 years. Oral Antibiotics Oral antibiotics will provide adequate coverage for most mild to moderate episodes of pneumonia. ID. full blood count findings or CRP do not reliably differentiate viral from bacterial pneumonia. There is no role for outpatient oral antibiotic therapy for infants < 3 months of age with pneumonia. BD (tablets only) * Oral amoxycillin dose has been increased from previous guidelines in view of increased pneumococcal resistance (consistent with international best practice). An NPA may be indicated for cohorting patients being admitted.Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Respiratory. Any printed version can not be assumed to be current. especially the child suspected of having Staphylococcus aureus or complicated pneumonia. Gen Paeds August 2010 .

Total duration of therapy is usually 7 -10 days. for several days after this. Please remember to read our disclaimer. ii.50 mg /kg/dose (maximum 2000 mg / dose) Interval (hrs) 8i 6ii 8 In term babies < 7 days old. in the case of severe pneumonia. Duration of therapy is determined by clinical response. iv. Antibiotic Cefotaxime + Amoxycillin Amoxycillin Dose 50 mg/kg/dose 50 mg/kg/dose 30. iii. ID. B) Complicated pneumonia < 3 months ≥3 months Cefotaxime and amoxycillin as above Amoxycillin + Clavulanic acid* OR Cefuroxime* 30mg/kg/dose (max 1. respiratory rate. Respiratory. if suspicion of mycoplasma consider addition of an oral macrolide Unimmunised children should be treated according to the complicated pneumonia recommendations below. and oxygen saturation. temperature. reduce to 8 hourly In a child > 5 years. no lung abscess nor pleural effusions) is: Age Less than 3 months ≥ 3 months (fully immunisediv) i. Shepherd & Twiss Dr Raewyn Gavin Page: Services: Date Reviewed: 4 of 8 CED. Brabyn. Parenteral antibiotics Should only be used for those requiring admission (see below) A) Pneumonia Not Likely To Be Staphylococcal Suggested empirical IV therapy for inpatients with uncomplicated pneumonia (no suspicion of staphylococcal disease.Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Monitor pulse rate.2g/dose q6h) 30mg/kg/dose (max 1. reduce to 12 hourly In term babies < 7 days old. Intravenous therapy should be used until the child is afebrile and. PNEUMONIA 2.5g/dose) 6-8 hourly 8 hourly * Following intravenous treatment options for oral antibiotics include amoxycillin-clavulanic acid syrup/tablets or cephalexin syrup/tablets Author: Editor: Pneumonia Drs Best. Any printed version can not be assumed to be current. Gen Paeds August 2010 .

Diagnosis should be confirmed by blood culture and/or aspirate. Complicated pneumonia. Deterioration despite appropriate oral antibiotics. (including significant atelectasis / collapse) or chronic / recurrent symptoms. *ID approval is required for use of Clindamycin >48 hours • • Multi-resistant-S. influenza or measles. full recoveries. ID. so Vancomycin is rarely required as empiric treatment. PNEUMONIA C) Probable Staphylococcal Pneumonia Staphylococcal pneumonia is classically associated with lung abscess and empyema. Staphylococcal pneumonia is a medical emergency – if you suspect it. Any printed version can not be assumed to be current. language or communication barrier Follow up Most children with pneumonia respond to quickly to treatment and make uneventful. Brabyn. Significant co-morbidity Social concerns: no car. Hypoxaemia: oxygen saturation less than 93% on air Respiratory distress interfering significantly with feeding. Resolution of cough is expected in 4-6 weeks and when this does not occur the family should see their General Practitioner for further follow up and consideration of referral to General Paediatric outpatient clinic. Shepherd & Twiss Dr Raewyn Gavin Page: Services: Date Reviewed: 5 of 8 CED. Please remember to read our disclaimer. Age < 3 months.aureus remains uncommon as a cause of pneumonia. Respiratory. Gen Paeds August 2010 . you must discuss the child with your consultant. Author: Editor: Pneumonia Drs Best. Consider it in any child who is very unwell. Flucloxacillin +/Clindamycin* Admission Indications for admission include any of the following: • • • • • • • • • Ill or toxic appearance. Appropriate initial IV antibiotics for probable S.aureus pneumonia are: 50mg/kg 6 hourly (max 2000mg/dose) 10mg/kg 6-8 hourly (max 450mg/dose) *Addition of clindamycin should be based on local methicillin resistant Staphylococcus aureus rate where >10% is suggestive of need to add anti-MRSa drug. Significant dehydration. Antibiotic choice should be rationalised once culture results available. has abscesses or metastatic infection or has developed pneumonia as a consequence of chicken pox. no phone.Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. A follow up chest x-ray is not routinely required but may be indicated in those with complicated pneumonia – see below.

Pneumonia Complications Health professionals caring for children with pneumonia should be aware of the range of potential complications. Definitive diagnosis requires contrast chest CT (see expert advice before requesting this). Author: Editor: Pneumonia Drs Best. Follow up should be arranged to ensure resolution as may be associated with long term sequelae. (c) Pneumatocoele: These are thin-walled air-filled cysts that develop within the parenchyma. including persisting fever. PNEUMONIA Children with recurrent pneumonia or persistent symptoms A history of recurrent pneumonia or chronic cough / respiratory symptoms should be sought at admission.Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. chronic lung disease or environmental factors (see table below). Respiratory. Careful follow up is recommended to ensure full recovery and resolution. Seek expert advice on management. Please remember to read our disclaimer. (b) Lung necrosis: Necrosis and liquefaction of lung tissue. They are particularly associated with Staphylococcus aureus and will usually resolve over time without specific intervention. Any printed version can not be assumed to be current. Shepherd & Twiss Dr Raewyn Gavin Page: Services: Date Reviewed: 6 of 8 CED. Children with persistent lobar collapse should be referred to a respiratory paediatrician for review and potentially a flexible bronchoscopy. Chest physiotherapy (airway clearance techniques) may be indicated. Family should be notified that it may be unsafe for the child to fly while the pneumatocoele(s) are present. ID. how to recognise them and their management. Brabyn. Gen Paeds August 2010 . This is recognised frequently in paediatric respiratory illness. It may be appropriate to discuss this referral prior to discharge from CED. Initial test is serum electrolytes. Consider symptomatic hyponatraemia if there is irritability. The following serves to highlight these complications but is not intended as a full list nor a comprehensive guide to their management. Additional therapy or surgical intervention is not necessarily required and outcome with conservative management in childhood is usually good. Careful follow up is required as long term sequelae may follow. History & clinical examination is the best starting point to investigate further.investigation of chronic cough &/or confirmed bronchiectasis’ The child with recurrent pneumonia or persistent symptoms needs referral to General Paediatric outpatient clinic with further investigations arranged. Most children should be managed with ¾ maintenance (see Intravenous Fluids guideline). This may be a sign of underlying vulnerabilities. See Starship Guideline on ‘COUGH . an altered level of consciousness. (d) Atelectasis / Lobar collapse: This is not uncommon. (a) Syndrome of inappropriate anti-diuretic hormone (SIADH): Inappropriate secretion of anti-diuretic hormone leads to retention of water and hyponatraemia. Suspicion may be raised by poor response to treatment.

ID. Children with parapneumonic effusions / empyema should be admitted on intravenous antibiotics (see complicated pneumonia above) to cover the likely organisms (Streptococcal species and Staphylococcus aureus but tuberculosis should be considered). foreign body. then additional intervention should be considered. Please remember to read our disclaimer. aren't making expected progress. (g) Chronic bronchitis / bronchiectasis (sequelae): Children with persistent symptoms and/or signs including chronic productive cough. Diagnosis is usually made by chest x-ray supported by contrast CT chest. Brabyn. full blood count and inflammatory markers should be obtained at diagnosis. persistent crackles. Shepherd & Twiss Dr Raewyn Gavin Page: Services: Date Reviewed: 7 of 8 CED. PNEUMONIA (e) Parapneumonic effusion / empyema: All children with pneumonia whose fever doesn’t settle on appropriate antibiotic therapy within 48hrs should be screened for a pleural collection (examination and chest x-ray). (f) Lung abscess: The symptoms and signs of lung abscess are the same as for pneumonia and they may be difficult to distinguish on clinical grounds alone. See Starship Guideline on ‘COUGH .investigation of chronic cough &/or confirmed bronchiectasis’ Prevention: Environment and underlying conditions associated with pneumonia Environmental factors • • • • • tobacco smoke exposure poor nutrition poor housing over-crowding lack of immunisation Underlying conditions • chronic lung diseases (chronic bronchitis / bronchiectasis) • cystic fibrosis • primary immunodeficiency • chronic aspiration • congenital lung malformation • airway malformation Author: Editor: Pneumonia Drs Best. usually a minimum of 4 weeks. and/or persistent signs of sepsis). Both of these interventions result in more rapid recovery than a chest drain or antibiotics alone. seek expert advise.Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. inflammatory markers and blood cultures are recommended. A chest ultrasound is useful pre-intervention to confirm. If you aren't familiar with empyema management. Any printed version can not be assumed to be current. Respiratory. or immunodeficiency should be carefully considered. If the child is significantly compromised (high work of breathing. Blood cultures. quantify and characterise the effusion. hypoxia. clubbing and/or x-ray findings should be evaluated further for possible underlying bronchitis/bronchiectasis. or the effusion is very large. The presence of underlying lung disease or malformation. Management of lung abscess should be guided by a respiratory paediatrician. Therapy is a prolonged course of antibiotics. Gen Paeds August 2010 . This will usually be video-assisted thorascopic surgery (VATS) with a chest drain or a chest drain with fibrinolytic therapy. Baseline full blood count. aspiration. Routine thoracocentesis or chest CT are not recommended.

pdf Craig JC. Jones M et al. Shepherd & Twiss Dr Raewyn Gavin Page: Services: Date Reviewed: 8 of 8 CED.34(4):355-9. Gadomski A.340:c1594. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. Brabyn. Aickin R. Kabra SK. Tan D. Thorax 2002.19(4):373-7. Please remember to read our disclaimer. WHO. Yee RL. McCracken GH Jr.3:CD004874. British Thoracic Society Standards of Care Committee. PNEUMONIA References Guidelines for the management of community acquired pneumonia. Respiratory.esr. Gen Paeds August 2010 .Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Antibiotics in childhood pneumonia. Etiology and treatment of pneumonia. Grant CC. Margolis P. Pediatr Infect Dis J.Geneva:14-35.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/paediatriccap. Tan TQ. 279(4):308-13. BMJ 2010. World Health Organization 1995.britthoracic. Cochrane Database Syst Rev.cri. Isaacs D. Wald ER et al. J Paediatr Child Health 1998. 2006. Lodha R. 2010. Practical guidelines for outpatient care. Hospitalisation for pneumonia in children in Auckland.nz/PDF_surveillance/Antimicrobial/MRSA/aMRSA_ Author: Editor: Pneumonia Drs Best. 2000. Pandey RM. http://www. Pediatrics 2002. Mason EO Jr. Williams GJ. ID.org. Hale KA. New Zealand.7(2):145-51.surv. Pati A. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15781 febrile illnesses. Paediatr Respir Rev. Scragg R. http://www. Any printed version can not be assumed to be current.57(Suppl I):1-24.110:1-6. The management of acute respiratory infections in children. Antibiotics for community-acquired pneumonia in children. Does this infant have pneumonia? JAMA 1998.