First-Ever Guidelines Issued for Pediatric Pneumonia

From Medscape Medical News Emma Hitt, PhD August 31, 2011 — The first-ever guidelines on the diagnosis and treatment of community-acquired pneumonia (CAP) in infants and children, from the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA), emphasize the importance of immunizations, including a yearly influenza vaccine, to protect children from life-threatening pneumonia. A 13-member panel, led by John S. Bradley, MD, with the Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, in California, authored the new guidelines published online August 30 and to appear in the October 1 issue of Clinical Infectious Diseases. The document presents 92 specific recommendations in all, each with varying levels of evidence. Currently, guidelines exist for the diagnosis and treatment of pneumonia in adults, but in the pediatric setting, bacterial pneumonia often takes a different course, even when caused by the same pathogens. Consequently, there is widespread variability in the treatment of CAP among children. The current document is "designed to provide guidance in the care of otherwise healthy infants and children and addresses practical questions of diagnosis and management of CAP evaluated in outpatient (offices, urgent care clinics, emergency departments) or inpatient settings in the United States," Dr. Bradley and colleagues write. Recommendations for Diagnosis "Diagnostic methods and treatments that work well in adults may be too risky and not have the desired result in children," noted Dr. Bradley in an accompanying written release from the PIDS and IDSA. Regarding diagnosis, the guidelines state that blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP treated in the outpatient setting. "In these cases, there is no need to perform unnecessary medical interventions such as using x-rays (which expose the child to radiation needlessly) or prescribing antibiotics (which kill bacteria, not viruses, and may foster drug-resistant bacteria)," the written release states. However, blood cultures should be performed in children "who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy," the study authors write. Hospitalization Based on Symptoms in Infants The guidelines also recommend that infants 3 to 6 months old with suspected bacterial pneumonia be hospitalized, even if the pneumonia is not confirmed by blood tests. "Blood testing in children often isn't accurate, so physicians need to pay close attention to symptoms, and, if unsure, err on the side of treating," Dr. Bradley indicates. Strong Recommendation for Immunizations All children and adolescents at least 6 months old should be immunized annually with vaccines for influenza virus to prevent CAP, which the study authors state is a strong recommendation, based on high-quality evidence. Parents of children younger than 6 months should be vaccinated against influenza because these children cannot receive the preventive vaccine. Amoxicillin Sufficient for First-Line Therapy In addition, amoxicillin should be used as first-line therapy for bacterial pneumonia, but more powerful antibiotics are not needed. Methicillin-resistant Staphylococcus aureus should be considered as a cause of pneumonia if first-line treatment is unsuccessful. According to the guidelines, overtreatment is a critical concern. Most cases of pneumonia in preschool-aged children are of viral origin and will therefore not develop into life-threatening bacterial pneumonia. Because of the difficulty in studying children, the guidelines all call for more research in several areas. "With these guidelines, we are hopeful that the standard and quality of care children receive for community-acquired pneumonia will be consistent from doctor to doctor — providing much better treatment outcomes," Dr. Bradley indicates. "We’re hopeful that in following these guidelines, physicians and hospitals will collect data and the results can be compared," he notes. "We envision this as the first of many revisions of guidelines to come." Guidelines Meet an Important Unmet Need Carrie Byington, MD, a pediatric infectious disease specialist with the Department of Pediatrics, at the University of Utah School of Medicine in Salt Lake City, notes that these guidelines address a very important unmet need for all practitioners who care for children. "Pneumonia is one of the most common reasons for hospitalization for children in the United States, and there's a huge variation in the care that's delivered to children," she told Medscape Medical News. Dr. Byington is an author on the new guidelines and is vice chair of the American Academy of Pediatrics Committee on Infectious Diseases. "Often the care of children is not evidence based and result in both over- and undertreatment of children and less than ideal outcomes," she said. "This is the first attempt to review all the evidence available in the scientific literature and to provide explicit guidelines for practitioners that could assist them in their decision making for children with pneumonia." Areas of Interest According to Dr. Byington, pediatricians in primary care will probably be most interested in the guidelines for diagnostic testing and the recommendation for antibiotic therapy. Pediatricians in the hospital setting will also be interested in the guidelines for hospitalized children, including diagnostic testing and treatment of complicated pneumonia. "We also really want to stress the prevention of pneumonia through immunization, so there is a large section to the research that demonstrates the importance of this," she said. This study was supported by the IDSA. Some of the study authors have disclosed various financial relationships with Wyeth/Pfizer, Sanofi Pasteur, Pfizer, GlaxoSmithKline, Novartis, Baxter Health Care, Halozyme Therapeutics, Pricara (Ortho-McNeil-Janssen), Rox-888, Venasite, the National Institutes of Health, and/or the Robert Wood Johnson Foundation. Clin Infect Dis. Published online August 30, 2011.