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Guidelines being drafted to aid in diagnosis of community-acquired pneumonia in pediatric patients
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John Bradley, MD, of the Rady Children’s Hospital and Infectious Diseases in Children Editorial Board member, spoke about issues related to diagnosing pneumonia, selecting appropriate treatment in the era of antibiotic resistance and the importance of vaccination.
In his presentation, Bradley reminded pediatricians that pediatric pneumonia is one of the most common causes of mortality in children worldwide, affecting 19% of the global distribution of children aged younger than 5 years. Viruses cause the majority (<90%) of pneumonia, particularly in infants, and Bradley said antibiotics are probably not needed as often as they are prescribed. In an infant or child with coryza, slight fever, no toxicity and bilateral rales, viral disease is likely and does not require antimicrobial therapy.
Although symptoms of fever, cough, dyspnea and systemic toxicity are recognizable symptoms of pneumonia, without reliable diagnostic methods, it is difficult to accurately assess pneumonia; and for those who need antibiotics, the right prescription is important in this era of increasing resistance and new vaccines such as the 13-valent pneumococcal conjugate vaccine (Prevnar 13, Wyeth).
“With Prevnar immunization, the overall resistance in pneumococcus, the overwhelmingly most common bacteria to cause pneumonia, has decreased to the point that we are going to recommend just amoxicillin for outpatients and just ampicillin for inpatients,” Bradley told Infectious Diseases in Children.
Bradley also discussed the significance of clinical clues. He noted, for instance, that the differences between acute and slowly progressive illness; the presence of clinical toxicity; upper respiratory tract symptoms; and discrepancies between bilateral and unilateral disease may be key to identifying pathogens.
Bradley also said physicians should be cautious of clues for tuberculosis, fungal causes and new viruses such as human metapneumovirus, bocavirus and SARS coronavirus when diagnosing pathogens that vary by exposure.
There is not a good test for outpatient pneumococcal pneumonia, he said, noting that blood culture should only be used for inpatients, and white blood count is not needed routinely. According to Bradley, it is difficult to diagnose mild to moderate pneumococcal pneumonia, as the white blood count, C-reactive protein and chest X-ray are not all that reliable. High white blood count and C-reactive protein are helpful but not sensitive enough for diagnosis, and chest auscultation/chest X-ray is a good method for diagnosis of respiratory syncytial virus but dismal for diagnosis of pneumococcal pneumonia.
Bradley said fever and cough are not good symptoms to verify the diagnosis of bacterial pneumonia.
“Coinfections with viruses and bacteria may be more common than we previously thought, as we get better techniques to diagnose viral lower respiratory tract infections,” he said.
At the 2010 AAP National Conference and Exhibition, Carrie L. Byington, MD, H.A. 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, said the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society are currently collaborating to create evidence-based recommendations for the national guidelines that will be released in 2011.