2021 Pneumonia Guidelines

Question 1

Clinical Question 1 AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT CLINICAL SIGNS AND SYMPTOMS WILL ACCURATELY DIAGNOSE COMMUNITY-ACQUIRED PNEUMONIA?

Answer 1

Pediatric community-acquired pneumonia (PCAP) is considered in a patient who presents with cough or fever, PLUS any of the following positive predictors of radiographically-confirmed pneumonia1: (Conditional recommendation, very low-grade evidence)

1. Tachypnea2
   1.1 3 months to 12 months old: ≥50 breaths per minute
   1.2 >1 year old to 5 years old: ≥40 breaths per minute
   1.3 >5 years to 12 years old: ≥30 breaths per minute 1.4 >12 years old: ≥20 breaths per minute
2. Retractions or chest indrawings
3. Nasal flaring
4. O2 saturation <95% at room air
5. Grunting

Question 2

Clinical Question 2 AMONG INFANTS AND CHILDREN 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT CLINICAL AND ANCILLARY PARAMETERS WILL DETERMINE THE NEED FOR ADMISSION?

Question 3

Clinical Question 3
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT DIAGNOSTIC AIDS WILL CONFIRM THE PRESENCE OF NONSEVERE COMMUNITY-ACQUIRED PNEUMONIA IN AN AMBULATORY SETTING?

Answer 3

Routine diagnostic aids are not considered for non-severe PCAP in an ambulatory setting. (Conditional recommendation, Expert opinion)

Question 4

Clinical Question 4
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT DIAGNOSTIC AIDS WILL CONFIRM THE PRESENCE OF SEVERE COMMUNITY-ACQUIRED PNEUMONIA IN A HOSPITAL SETTING?

Answer 4

KEY RECOMMENDATIONS

1. Chest X-ray is strongly recommended as an initial diagnostic aid for patients classified as having severe PCAP. (Strong recommendation, high-grade evidence)
2. Point-of-care chest ultrasonography (POCUS) performed by a skilled expert is strongly recommended as a diagnostic aid for patients classified as having severe PCAP. (Strong recommendation, high-grade evidence)
3. Procalcitonin (PCT) is recommended to be used in conjunction with other factors such as clinical presentation, imaging modalities and other laboratory aids in diagnosing bacterial PCAP. (Conditional recommendation, moderate-grade evidence)
4. Sputum Gram stain and culture are not considered to be done routinely in patients classified as having severe PCAP. (Conditional recommendation, low-grade evidence)
5. Complete blood count, arterial blood gas, serum electrolytes and other diagnostic aids are considered to be used as necessary based on the clinician’s evaluation. (Conditional recommendation, Expert opinion)

Question 5

Clinical Question 5
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT CLINICAL AND ANCILLARY PARAMETERS WILL DETERMINE THE NEED FOR ANTIBIOTIC TREATMENT?

Answer 5

KEY RECOMMENDATION Empiric antibiotic therapy is considered to be started in patients with clinical signs and symptoms of PCAP with ANY of the following parameters suggestive of bacterial etiology for both non-severe and severe pneumonia: (Conditional recommendation, low-grade evidence)

1. Elevated white blood cell count (WBC)7
2. Elevated C-reactive protein (CRP)
3. Elevated procalcitonin (PCT)
4. Imaging findings such as:
   4.1 Alveolar infiltrates in chest radiograph; or
   4.2 Unilateral, solitary lung consolidation and/or air bronchograms and/or pleural effusion in lung ultrasound

Question 6

Clinical Question
6A AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT EMPIRIC TREATMENT IS EFFECTIVE IF A BACTERIAL ETIOLOGY IS CONSIDERED?

Answer 6

KEY RECOMMENDATIONS

1. For patients classified as having non-severe PCAP, regardless of immunization status against Streptococcus pneumoniae and/or Haemophilus influenzae type b (Hib), any of the following is considered: 1.1 start Amoxicillin trihydrate at 40-50mg/kg/day Q8 for 7 days OR at 80-90mg/kg/day Q12 for 5 to 7days.
   1.2 start Amoxicillin-clavulanate at 80-90mg/kg/day Q12 (based on Amoxicillin content using a 14:1 amoxicillin:clavulanate formulation) for 5 to 7 days OR Cefuroxime at 2030mg/kg/day Q12 for 7 days in settings with documented high-level penicillin-resistant pneumococci or beta-lactamase-producing H. influenzae based on local resistance data or hospital antibiogram. (Conditional recommendation, low-grade evidence)
2. For patients classified as having severe PCAP, regardless of immunization status against Streptococcus pneumoniae, any of the following is considered:

2.1 start Penicillin G at 200,000 units/kg/day Q6 if with complete Haemophilus influenzae type b (Hib) vaccination OR Ampicillin at 200mg/kg/day Q6 if with no or incomplete or unknown Haemophilus influenzae type b (Hib) vaccination

2.2 start Cefuroxime at 100-150mg/kg/day Q8 OR Ceftriaxone at 75-100mg/kg/day Q12 to Q24 OR Ampicillin-sulbactam at 200mg/kg/day Q6 (based on ampicillin content) in settings with documented high-level penicillin-resistant pneumococci or betalactamase-producing H. influenzae based on local resistance data or hospital antibiogram

2.3 add Clindamycin at 20-40mg/kg/day Q6 to Q8 when Staphylococcal pneumonia is highly suspected based on clinical and chest radiograph features. However, in cases of severe and life-threatening conditions such as sepsis and shock, Vancomycin at 40-60 mg/kg/day Q6 to Q8 is preferred. (Conditional recommendation, low-grade evidence)

3. For patients with known hypersensitivity to penicillin, classified as 3.1 Non-type 1 hypersensitivity to Penicillin, cephalosporins such as Cefuroxime PO 2030mg/kg/day Q12 or IV 100-150mg/kg/day Q8 OR Ceftriaxone at 75-100mg/kg/day Q12 to Q24 is considered. 3.2 Type 1 hypersensitivity to Penicillin (immediate, anaphylactic-type), any of the following is considered: 3.2.1 Azithromycin at 10mg/kg/day PO or IV Q24 for 3 days OR 10mg/kg/day on day 1 followed by 5 mg/kg/day Q24 for days 2 to 5 3.2.2 Clarithromycin at 15mg/kg/day Q12 for 7 days 3.2.3 Clindamycin at 10-40mg/kg/day PO or 20-40mg/kg/day IV Q6 to Q8 for 7 days (Conditional recommendation, low-grade evidence) 4. When an atypical pathogen is highly suspected, starting a macrolide is considered as follows: 4.1 Azithromycin at 10mg/kg/day PO or IV Q24 for 5 days, particularly in infants less than 6 months old whom pertussis is entertained, OR 10mg/kg/day Q24 for 3-5 days OR 10mg/kg/day on day 1 followed by 5 mg/kg/day Q24 for days 2 to 5 4.2 Clarithromycin at 15mg/kg/day Q12 for 7 to 14 days (Conditional recommendation, low-grade evidence) 5. When a specific pathogen is identified, modifying the empiric treatment based on the antibiotic susceptibility pattern and/or the drug of choice is recommended. (Strong recommendation, high-grade evidence) 6. When treating for uncomplicated bacterial PCAP, 7 to 10 days treatment is considered but a longer duration may be required depending on the patient’s clinical response, virulence of the causative organism and eventual development of complications. (Conditional recommendation, low-grade evidence)

Question 7

Clinical Question
6B AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH BACTERIAL COMMUNITY-ACQUIRED PNEUMONIA, WILL THE ADDITION OF A MACROLIDE TO STANDARD EMPIRIC REGIMEN IMPROVE TREATMENT OUTCOME?

Answer 7

KEY RECOMMENDATION

The addition of a macrolide to standard beta-lactam antibiotic therapy is not considered in the empiric treatment of bacterial PCAP. (Conditional recommendation, very low-grade evidence)

Question 8

Clinical Question 7

AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT TREATMENT IS EFFECTIVE IF A VIRAL ETIOLOGY IS CONSIDERED?

Answer 8

KEY RECOMMENDATION

Oseltamivir is strongly recommended to be started immediately within 36 hours of laboratoryconfirmed influenza infection. (Strong recommendation, high-grade evidence)

Question 9

Clinical Question 8

AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT CLINICAL AND ANCILLARY PARAMETERS WILL DETERMINE A GOOD RESPONSE TO CURRENT THERAPEUTIC MANAGEMENT?

Answer 9

KEY RECOMMENDATIONS
1. For patients classified as having non-severe PCAP, good clinical response to current therapeutic management is considered when clinical stability is sustained for the immediate past 24 hours as evidenced by improvement of cough or normalization of core body temperature in Celsius in the absence of antipyretics within 24-72 hours after initiation of treatment. (Conditional recommendation, very low-grade evidence)

2. For patients classified as having severe PCAP, good clinical response to current therapeutic management is considered when clinical stability is sustained for the immediate past 24 hours as evidenced by ANY ONE of the following physiologic and ancillary parameters observed within 24-72 hours after initiation of treatment: 2.1 Absence or Resolution of hypoxia
   2.2 Absence or Resolution of danger signs9
   2.3 Absence or Resolution of tachypnea 2.4 Absence or Resolution of fever
   2.5 Absence or Resolution of tachycardia
   2.6 Resolving or Improving radiologic pneumonia
   2.7 Resolving or Absent chest ultrasound findings
   2.8 Normal or Decreasing CRP
   2.9 Normal or Decreasing PCT (Conditional recommendation, very low-grade evidence)

Question 10

Clinical Question 9

AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT CAN BE DONE IF THE PATIENT IS NOT RESPONDING TO CURRENT THERAPEUTIC MANAGEMENT?

Answer 10

KEY RECOMMENDATIONS 1. For patients classified as having non-severe PCAP and are not improving or clinically worsening within 24-72 hours after initiating therapeutic management, diagnostic evaluation is considered to determine if any of the following is present: (Conditional recommendation, low-grade evidence) 1.1. Coexisting or other etiologic agents 1.2. Etiologic agent resistant to current antibiotic, if being given 1.3. Other diagnosis 1.3.1.Pneumonia-related complication i. Pleural effusion ii. Necrotizing pneumonia iii. Lung abscess 1.3.2.Asthma 1.3.3.Pulmonary tuberculosis 2. For patients as having non-severe PCAP and are not improving or clinically worsening within 24-72 hours after initiating a therapeutic management, 2.1 and started on standard dose Amoxicillin at 40-50mg/kg/day, increasing the dose to 80-90mg/kg/day Q12 OR shifting to Amoxicillin-Clavulanate at 80-90mg/kg/day (based on Amoxicillin content using a 14:1 amoxicillin:clavulanate formulation) Q12 OR Cefuroxime at 20-30 mg/kg/day Q12 is considered. 2.2 and started on high-dose Amoxicillin, Amoxicillin-Clavulanate or Cefuroxime, admitting the patient for parenteral antibiotics is considered. 2.3 adding a macrolide is considered when an atypical pathogen is highly suspected: 2.3.1 Azithromycin at 10mg/kg/day PO or IV Q24 for 5 days, particularly in infants less than 6 months old whom pertussis is entertained, OR 10mg/kg/day Q24 for 3-5 days OR 10mg/kg/day on day 1 followed by 5 mg/kg/day Q24 for days 2 to 5 2.3.2 Clarithromycin at 15mg/kg/day Q12 for 7 to 14 days (Conditional recommendation, low-grade evidence)

Question 11

Clinical Question 9
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT CAN BE DONE IF THE PATIENT IS NOT RESPONDING TO CURRENT THERAPEUTIC MANAGEMENT?

Answer 11

3. For patients classified as having severe PCAP and are not improving or clinically worsening, within 24-72 hours after initiating a therapeutic management, diagnostic evaluation is considered to determine if any of the following is present:
   3.1 Coexisting or other etiologic agents
   3.2 Etiologic agent resistant to current antibiotic, if being given 3.3 Other diagnosis
   3.3.1 Pneumonia-related complication i. Pleural effusion ii. Pneumothorax iii. Necrotizing pneumonia iv. Lung abscess 3.3.2 Asthma
   3.3.3 Pulmonary tuberculosis
   3.3.4 Sepsis (Conditional recommendation, Expert opinion)
4. The following diagnostic evaluations are considered in the presence of treatment failure in severe PCAP:
   4.1 Cultures
   4.2 Nucleic acid amplification test (e.g. PCR) 4.3 Serology 4.4 Imaging modalities: (chest radiography, UTZ or CT scan) 4.5 Biomarkers (e.g. CBC, CRP, PCT) (Conditional recommendation, Expert opinion) CONTEXT AND CONSIDERATIONS 5. For patients that are not improving or clinically worsening within 24-72 hours after initiating a therapeutic management, a referral to a specialist is considered. (Conditional recommendation, Expert opinion)

Question 12

Clinical Question 10

AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT CLINICAL PARAMETERS WILL DETERMINE THAT SWITCH THERAPY CAN BE CONSIDERED IN THE MANAGEMENT OF SEVERE COMMUNITY-ACQUIRED PNEUMONIA?

Answer 12

KEY RECOMMENDATION

Switch therapy is considered among patients with bacterial PCAP when ALL of the following clinical parameters are present:

1. Current parenteral antibiotic has been given for at least 24 hours
2. Afebrile for at least 8 hours without the use of any antipyretic drug
3. Able to feed and without vomiting or diarrhoea
4. Presence of clinical improvement as defined by ALL of the following:
   4.1 Absence of hypoxia
   4.2 Absence of danger signs
   4.3 Absence of tachypnoea
   4.4 Absence of fever
   4.5 Absence of tachycardia (Conditional recommendation, low-grade evidence)

Question 13

Clinical Question 11

AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT ADJUNCTIVE TREATMENT IS EFFECTIVE FOR COMMUNITYACQUIRED PNEUMONIA?

Answer 13

KEY RECOMMENDATIONS
1. Vitamins A is strongly recommended as adjunctive treatment for measles pneumonia. (Strong recommendation, high-grade evidence)

2. Zinc is not considered as adjunctive treatment for severe PCAP as it does not have any effect in shortening recovery time. (Conditional recommendation, low-grade evidence)
3. Vitamin D is not considered as adjunctive treatment for severe PCAP as it does not reduce the length of hospital stay. (Conditional recommendation, low-grade evidence)
4. Bronchodilators are considered as adjunctive treatment for PCAP in the presence of wheezing. (Conditional recommendation, expert opinion)
5. Mucokinetic, secretolytic, and mucolytic agents are not considered as adjunctive treatment for PCAP. (Conditional recommendation, low-grade evidence)
6. There is insufficient evidence to recommend the use of the following as adjunctive treatment for PCAP: (Very low-grade evidence)
   6.1 Oral folate
   6.2 Probiotics
   6.3 Vitamin C
   6.4 Virgin coconut oil (VCO)
   6.5 Nebulization with saline solution
   6.6 Steam inhalation

Question 14

Clinical Question 12

AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 3 YEARS, WHAT INTERVENTIONS ARE EFFECTIVE FOR THE PREVENTION OF COMMUNITY-ACQUIRED PNEUMONIA?

Answer 14

KEY RECOMMENDATIONS

1. The following strategies are recommended to prevent PCAP:
   1.1 Vaccination against Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae type b (Hib), Bordetella pertussis (pertussis), Rubeola virus (measles) and Influenza virus (Strong recommendation; high-grade evidence) 1.2 Breastfeeding (Strong recommendation; high-grade evidence) 1.3 Avoidance of environmental tobacco smoke or indoor biomass fuel exposure (Strong recommendation; high-grade evidence)
   1.4 Zinc supplementation (Strong recommendation; moderate-grade evidence)
2. There is insufficient evidence to recommend Vitamin A, C or D supplementation for the prevention of PCAP. (Very low-grade evidence)