Community Acquired Pneumonia in ( CAP ) in Children ( >4 weeks old - <16 years age ) - Guidance for the management of

Publication: 12/12/2012  
Last review: 01/02/2018  
Next review: 01/02/2021  
Clinical Guideline
CURRENT 
ID: 1611 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for management of community acquired pneumonia (CAP) in children (>4 weeks old-<16 years of age)

Summary
Community Acquired Pneumonia in ( CAP ) in Children ( >4 weeks old - <16 years age )

Clinical Diagnosis

  • Fever, cough, difficulty breathing and tachypnoea.
  • Crackles often heard on auscultation, bronchial breathing is a later sign.
  • Reduced air entry and dull percussion note (PN) suggest pleural effusion/empyema.
  • In community acquired pneumonia (CAP), symptoms begin in the community or within 48 hours of admission.
  • Pathogen cannot reliably be determined by clinical presentation.
  • If influenza in circulation, see LTHT children’s influenza guideline.

Investigations

  • Pulse oximetry (all patients).
  • Consider CXR (in patients admitted to hospital). LINK WITH CXR GUIDANCE
  • Microbiological investigations in those requiring PICU admission or those with complications. These include blood culture, NPA or nose swab for viral PCR and/or immunofluorescence, respiratory viral and Mycoplasma/Chlamydia serology (acute and convalescent) and, if present, pleural fluid for microscopy, culture, and pneumococcal antigen detection and/or PCR.

General Management

  • Oxygen - to keep saturations above 92%.
  • NG tubes can compromise breathing - try to avoid in severely ill infants with small nasal passages. If necessary use the smallest tube down the smallest nostril.
  • If IV fluids needed measure U+E initially and at least daily.
  • Chest physiotherapy should not be routinely used in previously well children with uncomplicated pneumonia.

Antibiotic Management

  • All children diagnosed with pneumonia should receive antibiotics as it is not possible to distinguish between bacterial and viral pneumonia.
  • Amoxicillin electronic Medicines Compendium information on Amoxicillin is the first choice antibiotic in all children.
  • Oral antibiotics are safe and effective for most children.
  • Clarithromycin electronic Medicines Compendium information on Clarithromycin can be added if there is no response to Amoxicillin electronic Medicines Compendium information on Amoxicillin.
  • Clarithromycin electronic Medicines Compendium information on Clarithromycin should be used if Mycoplasma or Chlamydia are suspected or in very severe disease.
  • Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav should be used in pneumonia associated with influenza.
  • If a patient has already had appropriate treatment with Amoxicillin electronic Medicines Compendium information on Amoxicillin, consider treating with Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav or Clarithromycin electronic Medicines Compendium information on Clarithromycin.
  • IV antibiotics should be used for those unable to tolerate or absorb oral antibiotics or in those with septicaemia or complicated pneumonia. IV Amoxicillin electronic Medicines Compendium information on Amoxicillin or Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav can be used. Consider an oral switch once there is clear improvement.

Follow-up

  • Patients discharged should be given appropriate safety net advice.
  • Patients with severe pneumonia should be followed up on discharge.

Follow up CXR is not required in those who are previously healthy and who are recovering well but should be arranged, with clinical review, for those with a round pneumonia, collapse or persisting symptoms. 

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Background

“Community acquired pneumonia (CAP) can be defined clinically as the presence of signs and symptoms of pneumonia in a previously healthy child due to an infection which has been acquired outside hospital. In developed countries this can be verified by the radiological finding of consolidation." (1)

Pneumonia is a relatively common reason for children to come to hospital. UK data from 2001-2 showed an incidence of 14.4/10,000 children aged 0-15 years.(2) In those less than 5 years the incidence was higher at 33.8/10,000. Morbidity is significant in terms of length of illness, time off school etc.

The severity of infections and sequelae are influenced by both the pathogen and host susceptibility to infection such as the presence of underlying respiratory conditions or immunocompromise. This is supported by the finding that severe disease is more common in children under 5 years of age and in children with a history of prematurity (2).

Microbiology
Pneumonia can be caused by bacteria and viruses; about a third of cases represent a mixed infection (1).
Streptococcus pneumoniae is the single most common bacterial cause in children. Group A streptococci and Staphylococcus aureus are less common, but are more likely to progress to severe infections and empyema (1). S. aureus can cause severe disease following influenza and PVL (Panton Valentine Leukocidin) producing strains of S. aureus are associated with necrotising pneumonia (1). Although penicillin resistance among Streptococcus pneumoniae isolates is more prevalent in some parts of the world, this has not been seen to have a significant effect on clinical outcomes of pneumonia (1).

Mycoplasma and Chlamydia can cause community acquired pneumonia at all ages, with rates of detection of Mycoplasma reported at 27-36%.

Viruses cause 30-67% of cases, and are found more commonly in those under 1 year. Respiratory syncytial virus (RSV) is the most common viral aetiology. Others include adenovirus, parainfluenza, influenza and human metapneumovirus. (1)

Complications
Empyema, effusion and lung abscesses are potential complications of pneumonia. All these may prolong the illness and delay response to therapy. Necrotising pneumonia is a severe complication involving liquefaction of lung parenchyma and cavitation. There may also be an associated empyema.

One cause of necrotising pneumonia is Panton-Valentine leukocidin (PVL)- producing Staphylococcus aureus, which may not respond to standard antimicrobial treatment regimens. In children (particularly teenagers) who are rapidly deteriorating, and have bilateral changes and other features of severe pneumonia consider the possibility of Panton-Valentine Leukocidin (PVL) producing Staphylococcus aureus (particularly if there is a history of recurrent boils and soft tissue infections) and discuss urgently with microbiology.

Bloodstream infection and secondary foci of infection outside the respiratory tract may occur - consider osteomyelitis and septic arthritis, particularly with Staphylococcus aureus (1)

Streptococcus pneumoniae is a rare cause of haemolytic uraemic syndrome (HUS). Consider HUS in a child with anuria and profound anaemia. (1)

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Clinical Diagnosis

History
Pneumonia typically presents with fever, cough, difficulty breathing and tachypnoea. Wheeze, chest pain and abdominal pain may be present. Cough may be absent in the initial stages. Infants may have difficulty in feeding. In acutely ill febrile children, pneumonia may present as pain referred to the abdomen or as fever without source.

To satisfy a diagnosis of CAP, symptoms should have begun in the community or within 48 hours of admission to hospital. If respiratory symptoms develop >48 hours after admission to hospital this may constitute hospital acquired pneumonia and would warrant discussion with Microbiology.

Examination
Tachypnoea and increased work of breathing may be present. Crackles on auscultation are classical, with bronchial breathing as a later sign of consolidation. Reduced air entry and dull percussion note are suggestive of pleural effusion/empyema. Hypoxia can occur and is a marker of severity. Children may be pale or, in very severe cases, cyanosed. Prolonged fever (>7 days) associated with influenza may be a manifestation of secondary bacterial pneumonia.

It is worth noting that children with upper respiratory tract infections (URTI) and generalized wheeze with low grade fever may have viral induced wheeze and not pneumonia.

Atypical (predominantly Mycoplasma) pneumonia can present with cough, chest pain and wheezing. Arthralgia and headache may be present. Symptoms may be worse than signs would suggest, however clinical findings cannot reliably distinguish between the different causes of pneumonia.

Necrotising pneumonia, should be suspected when there is haemoptysis/airway bleeding, hypotension, tachycardia, high temperature (>39°C), myalgia, leucopenia, multi-lobar infiltrates on chest x-ray, very high CRP and raised CK (3).

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Severity Assessment

Severity assessment (taken from BTS guideline)

 

Mild to moderate         

Severe

Infants

Temperature <38.5

Temperature >38.5

Resp rate <50

Resp rate >70

Mild recession

Moderate to severe recession

Taking full feeds

Nasal flaring

 

Cyanosis

 

Intermittent apnoea

 

Grunting respiration

 

Not feeding

 

Tachycardia*

 

Capillary refill time ≥2 seconds

Older children

Temperature <38.5

Temperature >38.5

Respiratory rate
<50 breaths/min

Respiratory rate
>50 breaths/min

Mild breathlessness

Severe difficulty in breathing

No vomiting

Nasal flaring 

 

Cyanosis 

 

Grunting respiration 

 

Signs of dehydration 

 

Tachycardia*

*Values to define tachycardia vary with age and with temperature - see PAWS

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Investigation

Perform pulse oximetry - all children with CAP.

Consider a CXR in children admitted to hospital with pneumonia.  However, a CXR should not be considered a routine investigation in those thought to have community acquired pneumonia. Children with mild pneumonia who can be managed in the community do not routinely need a CXR. A lateral CXR should not be performed routinely.

Blood tests are not routinely needed but can be requested if felt to be clinically indicated. If IV fluids are needed, check U+E at baseline and at least daily. CRP is not useful in the management of pneumonia and should not be tested routinely.

Microbiological investigations are not routinely needed in those with milder disease.

Microbiological investigations are recommended in those with severe pneumonia sufficient to require PICU admission, or in those with complications. Investigations should include:

Blood culture, viral NPA or nasal swabs, acute and convalescent serology for respiratory viruses, Mycoplasma and Chlamydia. If present, pleural fluid should be sent for microscopy, culture, pneumococcal antigen detection and/or PCR.

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Treatment
Non-Antimicrobial Treatment
  • Recommendations:
    Oxygen is needed if SaO2 ≤92%. This can be administered by face mask or nasal cannula. Children requiring oxygen need at least 4 hourly observations, including oxygen saturations.
  • Fluids may be needed if child is too breathless or tired to feed. Electrolytes must be monitored at baseline and at least daily while on IV fluids. SIADH can be a complication of LRTI.
  • Nasogastric feeds can be used but a nasal tube may compromise breathing further and the smallest tube, passed in the smallest nostril, should be used. If respiratory distress is marked, NG feeds may not be tolerated and IV fluids should be given.
  • Chest physiotherapy has not been shown to be beneficial and should not be routinely used in previously well children with uncomplicated pneumonia.
  • Antipyretics/analgesia as needed.

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Empirical Antimicrobial Treatment
  • All children diagnosed with pneumonia should receive antibiotics as it is not possible to distinguish between bacterial and viral pneumonia.
  • Amoxicillin electronic Medicines Compendium information on Amoxicillin is the first choice antibiotic in all children.
  • Oral antibiotics are safe and effective for most children.
  • Clarithromycin electronic Medicines Compendium information on Clarithromycin can be added if there is no response to Amoxicillin electronic Medicines Compendium information on Amoxicillin.
  • Clarithromycin electronic Medicines Compendium information on Clarithromycin should be used if mycoplasma or chlamydia are suspected or in very severe disease.
  • Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav should be used in pneumonia associated with influenza.
  • If a patient has already had appropriate treatment with Amoxicillin electronic Medicines Compendium information on Amoxicillin, consider treating with Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav or Clarithromycin electronic Medicines Compendium information on Clarithromycin.
  • IV antibiotics should be used for those unable to tolerate or absorb oral antibiotics or in those with septicaemia or complicated pneumonia. IV Amoxicillin electronic Medicines Compendium information on Amoxicillin or Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav can be used. Consider an oral switch once there is clear improvement.
  • In penicillin allergy use Clarithromycin electronic Medicines Compendium information on Clarithromycin orally. In severe or complicated pneumonia, if minor penicillin allergy use cefuroxime, if anaphylaxis discuss with microbiology.
  • Duration of therapy should be determined by severity of infection and clinical response. 5 days of therapy may be sufficient for non-severe pneumonia, while up to 10 days may be required in severe cases. (N.B. longer duration of therapy may be required in empyema).

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Directed Antimicrobial Treatment (when microbiology results are known)

If microbiology results become available discuss on a case by case basis.

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Duration of Treatment

Duration of therapy should be determined by severity of infection and clinical response. 5 days of therapy may be sufficient for non-severe pneumonia, while up to 10 days may be required in severe cases. (N.B. longer duration of therapy may be required in empyema).

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Switch to oral agent(s)

In those on IV therapy consider an oral switch once there is clear improvement and oral medication is likely to be tolerated.

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Treatment Failure
  • If the child is still pyrexial or unwell at 48 hours reassess and consider:
    1. Is an appropriate drug at an appropriate dose being used? Consider adding Clarithromycin electronic Medicines Compendium information on Clarithromycin.
    2. Has a complication developed - empyema / lung abscess (rare) or metastatic infection? Consider requesting a CXR.
    3. Is the child immunocompromised / have an underlying condition, e.g., cystic fibrosis?
    4. Consider tuberculosis.

If there is a suspicion of pleural fluid on a CXR, a chest ultrasound should be performed. If fluid is confirmed on CXR, referral to the surgical team should be made plus discuss with the respiratory team.

Subsequent management

  • Patients discharged should be given safety net advice regarding expected course of illness and where to seek help if needed. They should seek medical attention if fever is not starting to settle after 48 hours, or if there is concern about persisting / worsening increased work of breathing.
  • Follow up CXR is not required in those who are previously healthy and who are recovering well but should be arranged, with clinical review, for those with a round pneumonia, collapse or persisting symptoms.
  • Patients with severe pneumonia should be followed up on discharge.
    Patients with empyema or lung abscess will need follow up and repeat CXR.

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Provenance

Record: 1611
Objective:

Aims

  • To provide a clinical tool to improve the management of community acquired pneumonia (CAP) in children (>4weeks to ≤16 years).
  • To promote a consistent approach to the management of CAP, thereby facilitating training and improved quality of care for children.
  • To provide an educational resource.
    The British Thoracic Society has published updated guidelines for the management of pneumonia in children, on which these guidelines are largely based. (1)

Objectives

  • To provide evidence-based recommendations for the diagnosis and appropriate investigation of community acquired pneumonia (CAP) in children.
  • To provide recommendations for non-antimicrobial aspects of management of CAP.
  • To provide evidence-based recommendations for the appropriate empirical or directed antimicrobial therapy of CAP.
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:

Community acquired pneumonia in children (CAP)

Target patient group: Children (>4 weeks old - <16 years age)
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

References  and Evidence levels:

  1. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax Oct 2011;66 Suppl 2:ii1-ii23.
  2. Clark JE, Hammal D, Hampton F, Spencer D, Parker L. Epidemiology of community-acquired pneumonia in children seen in hospital. Epidemiol Infect. Feb 2007;135(2):262-269.
  3. PVL Subgroup of the Steering Group on Healthcare Associated Infection. Guidance on the Diagnosis and management of PVL-associated Staphylococcus Aureus Infections (PVL-SA) in England. 2nd ed. London: Health Protection Agency; 2008.

Evidence levels:

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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