Community-Acquired Pneumonia in Children

Translated from the original French version published October 2009

This clinical guide is provided for information purposes and is not a substitute for the practitioners judgment.

GENERAL
VIRUS: most frequently involved pathogens in the first 2 years of life Pathogens involved according to childs age or severity of illness:
1-3 months 1-24 months 2-5 years 6-18 years All ages

Afebrile pneumonitis syndrome: Chlamydia trachomatis Respiratory syncytial virus and other respiratory viruses Bordetella pertussis

Respiratory syncytial virus and other respiratory viruses Streptococcus pneumoniae Haemophilus influenzae type b* Nontypeable Haemophilus influenzae Chlamydia trachomatis

Respiratory viruses Streptococcus pneumoniae Nontypeable Haemophilus influenzae Haemophilus influenzae type b* Mycoplasma pneumoniae Chlamydophila pneumoniae

Mycoplasma Severe pneumonia requiring pneumoniae hospitalization in intensive care unit: Streptococcus Streptococcus pneumoniae pneumoniae Staphylococcus aureus Chlamydophila Streptococcus pyogenes (group A) pneumoniae Haemophilus influenzae type b* Influenza viruses A or B Mycoplasma pneumoniae Adenovirus and other Adenovirus respiratory viruses

* Unlikely in children who have received at least 3 doses of Haemophilus influenzae type B (Pediacel) vaccine. New terminology for Chlamydia pneumoniae.

DIAGNOSIS
Patients may present the following signs and symptoms: Cough Fever Tachypnea with: s >60 breaths/minute in infants aged <2 months s >50 breaths/minute in infants aged between 2 and 12 months s >40 breaths/minute in toddlers aged 12 months to 5 years s >20 breaths/minute in children aged >5 years Intercostal, subcostal or supracostal retractions Presence of crackles Decreased vesicular breath sounds

Higher positive predictive value if more than one sign is present

When combinations of the above signs and symptoms are absent, diagnosis of pneumonia is unlikely (very high negative predictive value). Chest radiography recommended to confirm the diagnosis. REFERENCES

Jadavji T, Law B, Lebel MH, et al. A practical guide for the diagnosis and treatment of pediatric pneumonia. Can Med Assoc J. 1997;156:S703-S711. Low DE, Kellner JD, Allen U, et al. Community-acquired pneumonia in children: a multidisciplinary consensus review. Can J Infect Dis. 2003;14 Suppl B:3B-11B. Vanderkooi OG, Low DE, Green K, et al. Predicting antimicrobial resistance in invasive pneumococcal infections. Clin Infect Dis. 2005 May 1;40(9):1288-97. Please note that other references have been consulted.

www.cdm.gouv.qc.ca

TREATMENT GUIDELINES
Initial treatment is always empirical. At the present time, no test provides rapid information on the etiology of pneumonia. Treatment suggestions are adapted to the probability of a pathogen in the particular epidemiological context (outpatient or inpatient), underlying comorbidities or severity of the pneumonia.

Prevention:

- Smoke-free home - Vaccination: Haemophilus influenzae type b (Pediacel) vaccine; pneumococcal conjugate vaccine (Prevnar, Synflorix) - Routine use of antitussives not recommended - Oxygen therapy if hypoxemia

General care:

- Adequate hydration - Analgesic/antipyretic if necessary

Potential indications for hospitalization

Age <6 months Toxic or lethargic appearance Immunodeficiency Severe respiratory distress Oxygen requirement Underlying cardiac or pulmonary disease Complicated pneumonia Dehydration, inability to feed Vomiting Failure to respond to oral antibiotics Low parental involvement to ensure treatment compliance

Factors associated with Streptococcus pneumoniae resistance: - Age <2 years - Use of antibiotics in previous 3 months - Day care attendance - Hospitalization in previous 3 months If fever persists more than 48 to 72 hours after initiating therapy or if clinical deterioration: reassess the patient and search for complications (empyema).

Treatment of community-acquired pneumonia in children according to age

Age 1-3 months Afebrile pneumonitis syndrome 4 months4 years

First-line oral therapy*

Clarithromycin (Biaxin) 15 mg/kg/day BID x 10 days Azithromycin (Zithromax) 10 mg/kg DIE on 1st day then 5 mg/kg/day DIE x 4 days Amoxicillin 90 mg/kg/day TID x 7-10 days

Maximum dosage of first-line oral therapy

Second-line oral therapy*

Maximum dosage of second-line oral therapy

500 mg BID 500 mg DIE day 1 then 250 mg DIE x 4 days 1 500 mg BID

Hospitalize children who are febrile or hypoxic

Amoxicillin-clavulanate potassium (Clavulin) 90 mg/kg/day BID or TID x 7-10 days Clarithromycin (Biaxin) 15 mg/kg/day BID x 7-10 days Azithromycin (Zithromax) 10 mg/kg DIE on 1st day then 5 mg/kg/day DIE x 4 days Cefuroxime axetil (Ceftin) 30 mg/kg/day BID x 7-10 days Amoxicillin 90 mg/kg/day TID x 7-10 days Amoxicillin-clavulanate potassium (Clavulin) 90 mg/kg/day BID or TID x 7-10 days Cefuroxime axetil (Ceftin) 30 mg/kg/day BID x 7-10 days

1 000 mg BID 500 mg BID 500 mg DIE day 1 then 250 mg DIE x 4 days 500 mg BID

5-15 years

Clarithromycin (Biaxin) 15 mg/kg/day BID x 7-10 days Azithromycin (Zithromax) 10 mg/kg DIE on 1st day then 5 mg/kg/day DIE x 4 days

500 mg BID 500 mg DIE day 1 then 250 mg DIE x 4 days

1 500 mg BID 1 000 mg BID 500 mg BID

* The antibiotics are usually listed in alphabetical order of their generic name. Only one brand name product is listed although several manufacturers may market other brand names. A Canadian prospective cohort study (Vanderkooi et al, 2005) has shown a significantly lower risk of emergence of macrolide resistance with the use of clarithromycin (Biaxin, Biaxin Bid or Biaxin XL) as compared to azithromycin (Zithromax). Amoxicillin 50 mg/kg/day may be used in children without risk factors for antibiotic resistance and who have received the pneumococcal vaccine. The 7:1 (BID) formulation of amoxicillin-clavulanate potassium (Clavulin) is preferred because of its better GI tolerance. For certain clinicians, adverse GI effects are lessened with a combination of amoxicillin (45 mg/kg/day) and amoxicillin-clavulanate potassium (45 mg/kg/day).

Community-Acquired Pneumonia in Children

This guide was developed with the collaboration of the professional corporations (CMQ, OPQ), the federations (FMOQ, FMSQ) and Qubec associations of pharmacists and physicians.