Community Acquired Pneumonia - CAP (2 mo - 18 years)



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Community Acquired Pneumonia - CAP (2 mo - 18 years)

Probiotics

Immunization incomplete (<2 doses of PCV and HIB)

Patient appropriate for medical unit?

Ceftriaxone injection

Complete Blood Count, Serum
Blood Culture (Aerobic and Anaerobic), Serum
X-ray Chest, 2 view

Off pathway, consider chest ultrasound, consulting surgery / ICU / pulmonary / infectious disease

3rd generation oral cephalosporin x10 days

Meets discharge criteria?

X-ray results

> 3 months old?

Failed outpatient therapy?

NS Bolus
Basic Metabolic Panel, Serum

Empyema, lung abscess or pleural effusion?

Concern for influenza?

Consider pulmonary or ENT consults

X-ray Chest, 2 view

URI symptoms?

Contraindications to probiotics?

Ampicillin injection

Respiratory isolation, consider risk factors for MSSA/MRSA infection

Respiratory Viral Panel, Nasopharyngeal
Oseltamivir suspension
Respiratory Viral Panel, Nasopharyngeal

Repeat 2 view CXR, consider further diagnostic testing including chest ultrasound, consider infectious disease and pulmonary consults

Inclusion Criteria
  • Clinical concern for pneumonia
Exclusion Criteria
  • Recent admission to a hospital or care facility
  • Immunosuppressed, cancer
  • History of, or risk for, aspiration pneumonia
  • Chronic lung disease other than asthma (CF, Bronchopulmonary dysplasia, etc.)
  • Severe neuromuscular disorders (Muscular dystorphy, Spinal muscular atrophy, etc.)
  • Tracheostomy present or ventilator dependent
  • History of recent thoracic surgery or procedures
  • Risk factors for TB or exotic pathogens (i.e. zoonotic)
Clindamycin injection

Concern for foreign body?

> 4 years old?

Risk for atypical pneumonia?

Penicillin allergy?

Consider other source

Empyema, lung abscess or pleural effusion?

Criteria supporting ICU level care

  • Invasive ventilation via an artificial airway (intubation)
  • Noninvasive positive pressure ventilation (CPAP, BiPAP)
  • Pulse oximetry ≤ 90% with inspired oxygen of ≥ 50%
  • Respiratory failure or severe respiratory distress
  • Sustained tachycardia, inadequate blood pressure, or need for pressors
  • Lack of clinical improvement in symptoms

Off pathway, consider chest ultrasound, consulting surgery / ICU / pulmonary / infectious disease

Clinical severity assessment

Meets discharge criteria OR failed outpatient therapy?

Risk for atypical pnemonia?

Patient improving at 48-72 hours?

Signs of dehydration?

Immunization incomplete (<2 doses of PCV and HIB)

Add Azithromycin, consider mycoplasma, chlamydophila and pertussis testing if diagnosis unclear (rarely necessary)

Azythromycin suspension

Intensive Care Unit

  • Continue antibiotics
  • Respiratory support per protocol
  • Early mobilization
  • Perform tracheal aspirate and bronchial brushing for Gram stain and culture if intubated.
  • Pleural fluid testing if tapped (microscopy, culture, and bacterial PCR)
  • Respiratory isolation

Medical Unit

  • Continue antibiotics
  • O2 to keep saturations > 90%
  • Early mobilization
  • Frequent evaluation
  • Respiratory isolation

Admit to Floor

Risk for atypical pneumonia

  • > 5 years old
  • Non-ill appearing
  • Insidious onset (5-7 days ) or prolonged symptoms (> 3 days)
  • Headache, sore throat, cough, malaise
  • Non-focal pulmonary exam (i.e. diffuse rales)
  • Bilateral, diffuse, interstitial infiltrates on chest x-ray

Sputum Gram stain and culture if able to produce (no induced sputum)

Sputum Culture, Respiratory
Clindamycin suspension

Discharge criteria

  • Has NOT failed outpatient therapy
  • Reassuring vital signs
  • No hypoxia (SpO2 < 90%)
  • Mild or no increased work of breathing (grunting, retracting, tachypnea)
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 2 - 3 days
  • Parents comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Chest Physiotherapy (CPT)

  • No evidence that CPT improves the treatment of uncomplicated CAP.

Acute phase reactants

  • No evidence that CRP/ESR/procalcitonin improve the diagnosis or treatment of uncomplicated CAP. They may be useful in monitoring progress in complicated CAP.

Treatment course

  • Mild to moderate illnesss: 10 days of antibiotics, including both intravenous and oral antibiotics
  • Severe illness: 10-14 days, including both intravenous and oral antibiotics
  • Complicated CAP: consult pulmonary and infectious disease
  • Consider probiotics for patients on long term antibiotics
  • Follow up with PMD in 2-3 days

X-ray Chest, 1 view

Amoxicillin suspension

Meets ICU criteria?

Consider pediatric or pulmonary consult

Conclusive findings for CAP?

Repeat Chest X-ray

  • Not routinely useful in children who recover uneventfully from CAP.

Signs of treatment failure

  • No clinical improvement (Note: children with CAP may remain febrile at 48-72 hours which dosn't nessesarily imply treatment failure if other signs show improvement)
  • Continuing or worsening respiratory distress
  • Worsening laboratory or imaging
  • Development of complicated effusion or empyema

Factors increasing clinical concern for pneumonia

  • Tachypnea
  • Respiratory distress
  • Hypoxemia
  • Increased work of breathing
  • Altered mental status
  • Fever
  • Cough
  • Focal lung exam
  • Pleurtic chest pain
  • Abdominal pain

Penicillin allergy?

Consider other etiology

Add Azithromycin 10 mg/kg PO Qday on day one, 5 mg/kg PO Q day for days 2-5, consider mycoplasma, chlamydophila and pertussis testing if diagnosis unclear (rarely necessary)

Azythromycin suspension

May consider acute and convalescent serology for Mycoplasma, Pertussis and Chlamydia. May consider Oseltamivir (if concern for influenza).

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Blood Culture (Aerobic and Anaerobic), Serum
Ceftriaxone injection
ISTAT Venous Blood Gas and Lactate, Serum
Admit to ICU
Vancomycin injection
Respiratory Viral Panel, Nasopharyngeal
Azythromycin suspension

Consider for ICU admission

  • Altered mental status
  • Imminent or current respiratory failure or sepsis
  • Severe respiratory distress
  • Hypoxia despite FiO2 > 50%
  • Positive pressure ventilation

Treat appropriately

Outpatient treatment failure

  • Continued symptoms of CAP despite oral antibiotics for 3 days or worsening symptoms at any point.

May NOT need to change antibiotic class if switching to IV (eg. Amoxicillin -> Ampicillin).

Early mobilization

  • May be more effective than usual care at reducing the mean length of stay.




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