PEDIATRIC

COMMUNITY
ACQUIRED
PNEUMONIA
2012
SUMMARY OF RECOMMENDATIONS
PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA
Clinical Questions
1. WHO SHALL BE CONSIDERED AS HAVING CAP?
2. WHO WILL REQUIRE ADMISSION?
3. WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR
AMBULATORY PATIENTS?
4. WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR IN-
PATIENTS?
5. WHEN IS ANTIBIOTIC RECOMMENDED?
6. WHAT EMPIRIC TREATMENT SHOULD BE ADMINISTERED IF A
BACTERIAL ETIOLOGY IS STRONGLY CONSIDERED?
7. WHAT TREATMENT SHOULD BE INITIALLY GIVEN IF A VIRAL
ETIOLOGY IS STRONGLY CONSIDERED?
8. WHEN CAN A PATIENT BE CONSIDERED AS RESPONDING TO THE
CURRENTANTIBIOTIC?
9. WHAT SHOULD BE DONE IF A PATIENT IS NOT RESPONDING TO
CURRENT ANTIBIOTIC THERAPY?
10. WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA BE
STARTED?
 1. WHO SHALL BE CONSIDERED AS HAVING
CAP?

1.The presence of pneumonia may be considered

even without a chest radiograph in a patient
presenting with cough and/or respiratory
difficulty plus any of the following predictors of
radiographic pneumonia:
At the ER:
tachypnea as defined by WHO in a patient aged 3 months
to 5 years or fever at any age or oxygen saturation less
than or equal to 92% at room air at any in the absence of
any co-existing illness (neurologic, musculoskeletal, or
cardiac condition) that may potentially affect oxygenation
At the Out-Patient Clinic:
tachypnea as defined by WHO in a patient aged 3 months
to 5 years or fever at any age
 1. WHO SHALL BE CONSIDERED AS HAVING
CAP?

2. The presence of pneumonia should be

determined using a chest radiograph in
a patient presenting with
cough and/or respiratory difficulty in the
following situations:
Presence of dehydration aged 3 months to 5 years
Presence of severe malnutrition aged less than 7
years
high grade fever and leukocytosis aged 3 to 24
months without respiratory symptoms
2. WHO WILL REQUIRE ADMISSION?
1. Revised risk classification for pneumonia-
related mortality
 2. WHO WILL REQUIRE ADMISSION?

2. Patients under 5 years old and more than

5 years old who are classified as pCAP C
but whose chest x-ray is without any of
the following: effusion, lung abscess, air
leak or multilobar consolidation, and
whose oxygen saturation is > 95% at
room air can be managed initially on
an outpatient basis.
3. What diagnostic aids are initially
requested for ambulatory patients?

1. Chest x-ray may be requested to rule out

pneumonia-related complications or
pulmonary conditions simulating
pneumonia
It should not be routinely requested to
predict end-of-treatment clinical outcome
2. Chest x-ray, complete blood count, C-reactive
protein, erythrocyte sedimentation rate,
procalcitonin, or blood culture should not be
routinely requested to determine
appropriateness of antibiotic usage
4. What diagnostic aids are initially
requested for in-patients?

pCAP C the following ancillary/diagnostic

procedures should be done
to determine etiology:
Gram stain and/or culture and sensitivity of pleural
fluid when available
to assess gas exchange:
Oxygen saturation using pulse oximetry
Arterial blood gas
 4. What diagnostic aids are initially
requested for in-patients?
The following ancillary/diagnostic procedures may be done
to confirm clinical suspicion of multilobar consolidation, lung
abscess, pleural effusion, pneumothorax or pneumomediastinum:
Chest x-ray PA-lateral
to determine appropriateness of antibiotic usage:
C-reactiveprotein (CRP);Procalcitonin (PCT); Chest x-ray PA-lateral; White
Blood Cell (WBC) count; Gram stain of sputum or nasopharyngeal aspirate
to determine etiology
Sputum culture and sensitivity; Blood culture and sensitivity
to predict clinical outcome:
Chest x-ray PA-lateral; Pulse oximetry
to determine the presence of tuberculosis if clinically suspected:
Mantoux test (PPD 5-TU); Sputum smear for aid fast bacilli
to determine metabolic derangement:
Serum electrolytes; Serum glucose

*** For pCAP D, a referral to a specialist should be done

 5. WHEN IS ANTIBIOTIC
RECOMMENDED?
1. For pCAP A or B, an antibiotic may be administered if
a patient is
beyond 2 years of age or with high grade fever without wheeze
2. For pCAP C, an antibiotic
should be administered if alveolar consolidation on
chest x-ray is present
may be administered if a patient is with any of the
following:
Elevated serum C-reactive protein [CRP]
Elevated serum procalcitonin level [PCT]
Elevated white cell count
High grade fever without wheeze
Beyond 2 years of age

3. For pCAP D, a specialist should be consulted

 6. WHAT EMPIRIC TREATMENT SHOULD BE
ADMINISTERED IF A BACTERIAL ETIOLOGY IS
STRONGLY CONSIDERED?

1. For a patient who has been classified as pCAP A or

B without previous antibiotic,
DOC: Amoxicillin [40-50 mg/kg/day, maximum dose
of 1500 mg/day in 3 divided doses for at most 7 days]
Amoxicillin may be given for a minimum of 3 days
Amoxicillin may be given in 2 divided doses for a minimum of
5 days
azithromycin [10 mg/kg/day OD for 3 days or
10mg/kg/day at day 1 then 5 mg/kg/day for days 2 to 5,
maximum dose of 500mg/day], or
clarithromycin [15 mg/kg/day, maximum dose of 1000
mg/day in 2 divided doses for 7 days] may be given to
those patients with known hypersensitivity to amoxicillin
 6. WHAT EMPIRIC TREATMENT SHOULD BE
ADMINISTERED IF A BACTERIAL ETIOLOGY IS STRONGLY
CONSIDERED?

2. For a patient who has been classified as pCAP C, without

previous antibiotic,
requiring hospitalization and
1. has completed the primary immunization against H.influenza type
b, penicillin G [100,000 units/kg/day in 4 divided doses]
administered as monotherapy is the drug of choice
2. has not completed the primary immunization or immunization
status unknown against H. influenza type b, ampicillin [100
mg/kg/day in 4 divided doses] administered as monotherapy is the
drug of choice
3. >15 years of age, a parenteral non-antipseudomonal -lactam
(-lactam/-lactamase inhibitor combination (BLIC), cephalosporin
or carbapenem] + extended macrolide [azithromycin or
chlarithromycin], or a parenteral non-antipseudomonal -
lactam [-lactam/ -lactamase inhibitor combination (BLIC],
cephalosporin or carbapenem] + respiratory fluoroquinolones
[levofloxacin or moxifloxacin] administered as combination therapy
may be given
 6. WHAT EMPIRIC TREATMENT SHOULD BE
ADMINISTERED IF A BACTERIAL ETIOLOGY IS STRONGLY
CONSIDERED?

2. For a patient who has been classified as

pCAP C, without previous antibiotic,
and who can tolerate oral feeding and does
not require oxygen support, amoxicillin [40-
50 mg/kg/day, maximum dose of 1500 mg/day
in 3 divided doses for at most 7 days] may be
given on an outpatient basis
6. WHAT EMPIRIC TREATMENT SHOULD BE
ADMINISTERED IF A BACTERIAL ETIOLOGY IS STRONGLY
CONSIDERED?

3. For a patient classified as pCAP C who is

severely malnourished or suspected to
have methicillin-resistant Staphylococcus
aureus, or classified as pCAP D, referral
to a specialist is highly recommended
4. For a patient who has been established
to have Mycobacterium tuberculosis
infection or disease, antituberculous
drugs should be started
7. WHAT TREATMENT SHOULD BE INITIALLY GIVEN IF A
VIRAL ETIOLOGY IS STRONGLY CONSIDERED?

1. Oseltamivir (30 mg twice a day for 15

kg body weight, 45 mg twice a day for
>15-23 kg, 60 mg twice a day for >23-40
kg, and 75 mg twice a day for >40 kg)
remains to be the drug of choice for
laboratory confirmed, or clinically
suspected cases of influenza.
2. The use of immunomodulators for the
treatment of viral pneumonia is not
recommended
8. WHEN CAN A PATIENT BE CONSIDERED AS
RESPONDING TO THE CURRENTANTIBIOTIC?

1. Decrease in respiratory signs and/or

defervescense within 72 hours after
initiation of antibiotic are predictors of
favorable response
2. If clinically responding, further diagnostic
aids to assess response such as chest x-
ray, C-reactive protein and complete
blood count should not be routinely
requested
 9. WHAT SHOULD BE DONE IF A PATIENT IS NOT
RESPONDING TO CURRENT ANTIBIOTIC THERAPY?

1. If an outpatient classified as either pCAP A or

pCAP B is not responding to the current antibiotic
within 72 hours, consider any of the following
Other diagnosis.
Coexisting illness.
Conditions simulating pneumonia

Other etiologic agents for which C-reactive protein,

chest x-ray or complete blood count may be used to
determine the nature of the pathogen.
May add an oral macrolide if atypical organism is highly
considered.
May change to another antibiotic if microbial resistance is
highly considered.
 9. WHAT SHOULD BE DONE IF A PATIENT IS NOT
RESPONDING TO CURRENT ANTIBIOTIC THERAPY?

2. If an inpatient classified as pCAP C is not responding to the

current antibiotic within 72 hours, consider any of the
following:
Other diagnosis:
Coexisting illness.
Conditions simulating pneumonia.

Consider other etiologic agents for which C-reactive protein,

chest x-ray or complete blood count may be used to determine
the nature of the pathogen.
Mayadd an oral macrolide if atypical organism is highly considered.
May change to another antibiotic if microbial resistance is highly
considered.
May refer to a specialist.
3. If an inpatient classified as pCAP D is not responding to the
current antibiotic within 72 hours, immediate consultation
with a specialist should be done
 10. WHEN CAN SWITCH THERAPY IN
BACTERIAL PNEUMONIA BE STARTED?

1. For pCAP C,
switch from intravenous antibiotic administration to oral
form 3 days after initiation of current antibiotic is
recommended in a patient who should fulfill all of the
following:
Responsive to current antibiotic therapy as defined in Clinical
Question 8 (Decrease in respiratory signs and/or defervescense within 72 hours
after initiation of antibiotic are predictors of favorable response)
Tolerance to feeding and without vomiting or diarrhea.
Without any current pulmonary (effusion/empyema; abscess; air leak,
lobar consolidation, necrotizing pneumonia) or extrapulmonary
complications; and
Without oxygen support.

switch therapy from three [3] days of parenteral ampicillin to

amoxicillin [40-50 mg/kg/day for 4 days]
2. For pCAP D, referal to a specialist should be
considered
 11. WHAT ANCILLARY TREATMENT CAN BE
GIVEN?

1. For pCAP A or B,
cough preparation , elemental zinc vitamin A vitamin D, probiotic
and chest physiotherapy should not be routinely given during
the course of illness.
a bronchodilator may be administered in the presence of
wheezing
2. For pCAP C,
oxygen and hydration should be administered whenever
applicable
Oxygen delivery through nasal catheter is as effective as using nasal prong
a bronchodilator may be administered only in the presence of
wheezing
2.2.1. Steroid may be added to a bronchodilator
a probiotic may be administered
cough preparation, elemental zinc, vitamin A, vitamin D and chest
physiotherapy should not be routinely given during the course of
illness
3. For pCAP D, referal to a specialist should be considered
 12. HOW CAN PNEUMONIA BE PREVENTED?

1. The following should be given to prevent pneumonia:

Vaccine against
Streptococcus pneumonia (conjugate type)
Influenza Diphtheria, Pertussis, Rubeola, Varicella, Haemophilus
Influenzae type b
Micronutrient.
1.2.1.
Elemental zinc for ages 2 to 59 months to be given for 4 to 6
months
2. The following may be given to prevent pneumonia:
Micronutrient.
Vitamin D3 supplementation
3. The following should not be given to prevent
pneumonia:
Micronutrient
Vitamin A
reference
2012 SUMMARY OF
RECOMMENDATIONS
PEDIATRIC COMMUNITY ACQUIRED
PNEUMONIA