PIDS/IDSA releases clinical practice guidelines on CAP in children

Bradley JS. Clin Infect Dis. 2011;doi:10.1093/cid/cir531.

The first-ever guidelines on diagnosis and treatment of community-acquired pneumonia in infants and children were released today by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.

The 52-page joint guidelines recommend immunizations as the best way to protect children from severe pneumonia and call for prevention of bacterial pneumonia as a top priority. Bacterial pneumonia in children can present differently than in adults, and treatment varies among clinicians. The new PIDS/IDSA guidelines are designed to provide all physicians who care for children with a roadmap to the most scientifically valid diagnosis and treatment recommendations.

“Diagnostic methods and treatments that work well in adults may be too risky and not have the desired result in children,” John S. Bradley, MD, lead author of the community-acquired pneumonia (CAP) guidelines, said in a press release. “With these guidelines, we are hopeful that the standard and quality of care that children receive for [CAP] will be consistent from doctor to doctor — providing much better treatment outcomes.”

John S. Bradley

The guidelines emphasize the importance of annual influenza vaccination in children aged at least 6 months because viral infections can pre-empt bacterial pneumonia. Clinicians should also strive to ensure that all infants and children are up to date on their other routine childhood vaccines because many of them prevent bacterial pneumonia, according to Bradley, who is a member of the Infectious Diseases in Children Editorial Board.

Overtreatment is a concern

Proper diagnosis of pneumonia is a paramount, but the guidelines also warn that overtreatment is of critical concern. Most cases of pneumonia in preschool-aged children are viral and will not develop into life-threatening bacterial pneumonia. Therefore, X-rays or antibiotics are unnecessary.

“A child with chest congestion, a cough, runny nose and low-grade fever likely has viral pneumonia, and Mother Nature treats those herself,” Bradley said. “If the child has a fever of 104·F, is barely able to keep fluids down, just wants to lie in bed and is breathing fast, it may be bacterial pneumonia and require antibiotics and hospitalization.”

The guidelines also suggest when doctors can feel comfortable not prescribing a higher level of care and when they should be cautious and move forward with the next level of care. The topic of when to hospitalize a child with CAP is the first section of the guidelines.

“Most of these kids will have their first encounter when they have fever and difficulty breathing and see their primary care physician, or the emergency room doctor,” Bradley said. “The first major decision that needs to be made is: Is this child well enough to go home, or does he or she need a higher level of care?”

The guidelines recommend that infants aged 3 to 6 months with suspected bacterial pneumonia would likely benefit from hospitalization, even if the pneumonia is not confirmed by blood tests. Blood testing in children is often inaccurate; therefore, physicians should closely evaluate the patient’s symptoms and err on the side of treating if unsure, according to Bradley.

Clinical practice guidelines

The evidence-based guidelines are intended to provide guidance in the care of otherwise healthy infants and children. The authors said the guidelines are meant to address practical questions about diagnosis and management of CAP evaluated in outpatient and inpatient settings. The guidelines are separated into the following categories:

• Site-of-care management decisions;
• Diagnostic testing for pediatric CAP;
• Anti-infective treatment;
• Adjunctive surgical and non-anti-infective therapy for pediatric CAP;
• Management of the child not responding to treatment;
• Discharge criteria; and
• Prevention.

For each of the 92 specific recommendations, the guidelines denote the strength of the recommendation, as well as the quality of evidence for each. The guidelines note the lack of solid evidence in some areas, which is often a result of the ethical challenges of studying children, and call for research in specific areas.

“We’re hopeful that in following these guidelines, physicians and hospitals will collect data and the results can be compared,” Bradley said. “We envision this as the first of many revisions of guidelines to come.”

Disclosure: The study was supported by IDSA. Dr. Bradley has received no pharmaceutical funding or support during the past 36 months for management of pediatric CAP.

Follow the PediatricSuperSite.com on Twitter.