pneumonia%20-%20community-acquired%20(pediatric)
PNEUMONIA - COMMUNITY-ACQUIRED (PEDIATRIC)
Community-acquired pneumonia is the presence of signs and symptoms of lower respiratory tract infection acquired outside of the hospital.
The most common bacterial cause of childhood pneumonia is Streptococcus pneumoniae. It usually causes about 1/3 of radiographically-confirmed pneumonia in children <2 years of age.
Viruses commonly affects children <1 year of age than those aged > 2 years, respiratory syncytial viruses (RSV) being the most frequently detected virus.
Mixed infection may occur in 8-40% of community-acquired pneumonia cases.

Principles of Therapy

  • Therapy is usually empiric & is based on age-specific causes of community-acquired pneumonia (CAP), disease severity & local resistance patterns of predominant pathogens
    • If blood or respiratory tract specimen culture has identified the causative agent, a safe, narrow-spectrum & effective therapy should be given
  • Oral route is safe & effective for outpatients w/ bacterial pathogen that most commonly cause lower respiratory tract infections 
  • Parenteral route is preferred in patients w/ severe disease or are unable to tolerate oral drug intake (eg vomiting) to ensure adequate blood & tissue concentrations
  • Antimicrobials are not warranted, may cause drug toxicity, & may facilitate development of antimicrobial resistance in young patients w/ clinical features suggestive of upper & lower respiratory tract viral infections
  • Empiric therapy for some children require both antimicrobial & antiviral agents

Indications for Hospital Admission

  • Children & infants who have moderate to severe community-acquired pneumonia (CAP), as defined by the presence of respiratory distress (eg tachypnea, dyspnea, suprasternal/intercostal/subcostal retractions, grunting, nasal flaring, apnea, altered mental status, pulse oximetry measurement <90% on room air)
  • Patients <3-6 months old w/ possible bacterial CAP
  • Children & infants w/ suspected or documented CAP caused by an agent w/ increased virulence [eg community-associated Methicillin-resistant Staphylococcus aureus (CA-MRSA)]
  • Patients whom there is concern about careful observation at home or who may be unable to comply w/ medications or cannot be followed-up
  • Presence of significant comorbid conditions
  • Presence of dehydration, vomiting, inability to take oral medications
  • Patients w/ unsuccessful outpatient oral antimicrobial treatment, & those w/ new & progressive respiratory distress
Indications for Intensive Care Unit Admission1
  • Patient w/ ≥1 major or ≥2 minor criteria should be transfered to an intensive care unit or a unit w/ continuous cardiorespiratory monitoring
    • Major criteria: Invasive mechanical ventilation, fluid refractory shock, acute need for noninvasive positive pressure ventilation (NIPPV), hypoxemia requiring fraction of inspired oxygen (FiO2) > inspired concentration
    • Minor criteria: Tachypnea, apnea, retractions, dyspnea, nasal flaring, grunting, arterial oxygen pressure (PaO2)/FiO2 <250, multilobar infiltrates, Pediatric Early Warning Score (PEWS) >6, altered mental status, hypotension, presence of effusion, comorbid conditions, unexplained metabolic acidosis
1 Adapted from: 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 guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e5.

Pharmacotherapy

Penicillins

Amoxicillin
  • 1st-line agent at any age if S pneumoniae is the likely pathogen
    • May also be given to patients w/ pneumonia caused by β-lactamase-negative strains (eg H influenza)
  • Has broader spectrum of activity, better oral pharmacokinetics (better absorption from gastrointestinal tract) & tolerability (less frequent dosing & better taste) as compared w/ Penicillin
  • Preferred step-down oral therapy for hospitalized patients initially treated w/ Ampicillin for S pneumoniae or β-lactamase negative H influenza infection
    • May also be given as step-down therapy in patients initially treated w/ broad-spectrum antimicrobials in whom no cultures are obtained or mere only obtained after starting antibiotics
Ampicillin or Penicillin G
  • Recommended for hospitalized, fully immunized infants & school-aged children when local epidemiologic data shows lack of resistance for invasive S pneumoniae
    • Also considered as 1st-line option in hospitalized patients w/ group A Streptococcus infections
  • Ampicillin is the preferred agent for infections caused by β-lactamase negative H influenza
  • Penicillin G represents the most narrow-spectrum & effective antibiotic for pneumococcal infections but requires a more frequent dosing interval
  • Also active against S pyogenes that causes severe necrotizing pneumonia
Antistaphylococcal Penicillin
  • Eg Oxacillin [intravenous (IV)], Nafcillin (IV)
  • Used for patients admitted in the hospital for Methicillin-susceptible S aureus (MSSA) infection
Penicillin w/ beta-lactamase inhibitor
  • Eg Amoxicillin/clavulanic acid, Ampicillin/sulbactam
  • Amoxicillin/clavulanic acid is the preferred oral step-down therapy for infections caused by β-lactamase producing H influenza
    • May also be given through intravenous route in patients w/ severe CAP which has been shown to be as effective as Ceftriaxone for strains w/ Amoxicillin minimum inhibitory concentration (MIC) of up to 2 micrograms/mL
Macrolides
  • Eg Azithromycin, Clarithromycin, Erythromycin, Roxithromycin
  • 1st-line agent in school-aged children & adolescents w/ atypical pneumonia eg M pneumoniae
  • Not advised as empiric therapy for pneumococcal CAP because currently isolated strains of S pneumoniae have shown significant resistance against macrolides
  • Azithromycin is the preferred agent for M pneumoniae, C pneumoniae or C trachomatis infections
Cephalosporins
  • 1st generation drugs (eg Cefazolin IV) may be used for inpatients w/ MSSA infection
  • 2nd generation (eg Cefuroxime) or 3rd generation (eg Ceftriaxone, Cefotaxime) agents are active against both β-lactamase-negative & -positive strains
    • Parenteral Ceftriaxone or Cefotaxime are recommended in hospitalized infants & children that are incompletely immunized, in places where local epidemiology shows lack of resistance for invasive S pneumoniae, or in infants & children w/ life-threatening infection (eg empyema)
      • Also the preferred agent for infections caused by β-lactamase producing H influenza
    • IV Ceftriaxone is the preferred agent for penicillin-resistant S pneumoniae
    • Intramuscular (IM) injection of Ceftriaxone may be given once a day as an outpatient therapy
    • Oral Cefpodoxime, Cefprozil or Cefuroxime may be considered as alternative agents in patients w/ allergies to Amoxicillin
  • Also active against S pyogenes causing severe necrotizing pneumonia
Quinolones
  • Eg Levofloxacin
  • May be used as an alternative to patients w/ history of severe allergy to Amoxicillin
  • Have comparable effect as w/ macrolides & tetracyclines in treating patients w/ M pneumoniae infection
  • Preferred oral step-down therapy in patients infected w/ Penicillin-resistant S pneumoniae
Tetracyclines
  • Eg Doxycycline
  • For childn >8 years w/ Macrolide-resistant M pneumoniae
Other Antibiotics
  • Vancomycin is the 1st-line agent for infections caused by community-acquired Methicillin resistant S aureus (CA-MRSA)
  • Linezolid is the preferred oral step-down therapy & an alternative parenteral agent for CA-MRSA infections
    • Useful especially in patients w/ pre-existing renal impairment or is receiving other nephrotoxic drugs
    • May be given to children w/ severe allergy to β-lactam drugs who can not tolerate Vancomycin or Clindamycin but should be used w/ caution since it has relatively high adverse effect profile
  • IV Clindamycin may be used as an alternative agent in patients w/ infections caused by susceptible MSSA or MRSA but is not recommended in patients w/ empyema
Influenza Antiviral Therapy
  • Should be administered as soon as possible to patient w/ moderate to severe CAP caused by Influenza virus infection, specifically to those w/ clinically worsening CAP during outpatient visit
  • Should not wait for the results of confirmation test since early treatment has been shown to provide maximal advantage
  • May still be of benefit when used after 48 hours of symptomatic infection in patients w/ more severe disease
Combination Therapy
  • Macrolide plus β-lactam antibiotic may be given to inpatients w/ probable M pneumoniae & C pneumoniae
  • Vancomycin or Clindamycin should be added to β-lactam antibiotic in patients highly considered to have S aureus infection, depending on local susceptibility data
    • Clindamycin plus β-lactam is recommended in children w/ toxic-like syndrome
Duration of Therapy
  • 10 days treatment course have been well studied but shorter period may be similarly effective for mild CAP
  • CA-MRSA infections may require longer treatment duration than those caused by S pneumoniae
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