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An Official Publication of the

Philippine Academy of Pediatric Pulmonologists, Inc.

PAPP PERSPECTIVE

3rd PAPP Update [2016]

in the

Evaluation and Management of

Pediatric Community-acquired Pneumonia

2016 PAPP Task Force on pCAP


PHILIPPINE ACADEMY OF PEDIATRIC PULMONOLOGISTS, Inc. [PAPP, Inc.]
rd
2016 PAPP Task Force on pCAP: 3 PAPP Update [2016] in the Evaluation and Management
of Pediatric Community-acquired Pneumonia.

All rights reserved. Publication and request for permission to reproduce should be obtained from the
Philippine Academy of Pediatric Pulmonologists, Inc., Room 4, 4/F Philippine Pediatric Society
Building, 52 Kalayaan Avenue, Barangay Malaya, Quezon City 1100 Philippines. Telefax Number [632]
3328855. Email address: papp_office@yahoo.com. Website:http://www.papp.org.ph

PHILIPPINE ACADEMY OF PEDIATRIC PULMONOLOGISTS, Inc. [PAPP, Inc.]


2016-2017 Board of Directors
Mary Therese M. Leopando, MD FPPS FPAPP President
Mary Ann F. Aison, MD FPPS FPAPP Vice president
Regina M. Canonizado, MD FPPS FPAPP Secretary
Nepthalie R. Ordonez, MD FPPS FPAPP Treasurer
Anna Marie S. Putulin, MD FPPS FPAPP Director
Amelia G. Cunanan, MD FPPS FPAPP Director
Lydia K. Chang, MD FPPS FPAPP Director
Clara R. Rivera, MD FPPS FPAPP Immediate past president

2016 PAPP Task Force on pCAP


Cristan Q. Cabanilla, MD FPPS FPAPP Chair
Emily B. Gaerlan-Resurreccion, MD FPPS FPAPP Secretary
Vivian A. Ancheta, MD FPPS FPAPP Member
Gari D. Astrologio, MD DPPS DPAPP Member
Janet C. Bernardo, MD FPPS FPAPP Member
Alfredo L. Bongo Jr, MD FPPS FPAPP Member
Janet Myla Q. Bonleon, MD FPPS FPAPP Member
Lydia K. Chang, MD FPPS FPAPP Member
Edward A. Chua, MD DPPS DPAPP Member
Julie Iris C. Clapano, MD FPPS DPAPP Member
Amelia G. Cunanan, MD FPPS FPAPP Member
Beverly D. de la Cruz, MD FPPS DPAPP Member
Anjanette R. de Leon, MD FPPS FPAPP Member
Yadnee V. Estrera, MD DPPS DPAPP Member
Jean Marie E. Jamero, MD DPPS DPAPP Member
Arnold Nicholas T. Lim, MD DPPS DPAPP Member
Grace V. Malayan, MD FPPS FPAPP Member
Beatriz Praxedez Apolla I. Mandanas, MD DPPS DPAPP Member
Raymund Anthony L. Manuel, MD DPPS DPAPP Member
Vicente Carlomagno D. Mendoza, MD FPPS DPAPP Member
Doris Louise C. Obra, MD FPPS FPAPP Member
Catherine S. Palaypayon, MD DPPS DPAPP Member
Cynthia Theresa M. Rimando, MD FPPS DPAPP Member
Ernesto Z. Salvador, MD DPPS DPAPP Member
Marion O. Sanchez, MD FPPS FPAPP Member
Josy Naty M. Venturina, MD DPPS DPAPP Member
Rozaida R. Villon, MD FPPS FPAPP Member
Nilyn Elise O. Ygnacio, MD DPPS DPAPP Member
Dahlia L. Yu, MD DPPS DPAPP Member

2
CONTENTS

Preface

Introduction

Methodology Overview

Disclaimer

Update Recommendations
Clinical Questions
Background: 2nd PAPP Update [2012]
Recommendations
3rd PAPP Update [2016] Recommendations
Summary of Evidence

Bibliography

Appendix

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PREFACE
The Philippine Pediatric Society in 2004 spearheaded the publication of the Clinical Practice Guideline
in the Evaluation and Management of Pediatric Community-acquired P n e u m o n i a [pCAP]. Because of
the important, unresolved issues and concerns on pCAP in the following years, the Philippine
Academy of Pediatric Pulmonologists [PAPP] drafted the first Update in the Evaluation and
Management of pCAP in 2008. Revisions on several recommendations b a s e d on recent evidences
from local and foreign literature were published in the second PAPP Update in 2012. The PAPP Task
Force on pCAP in 2016 felt the need to come up with the third Update on pCAP to include new
developments on recommendations in the evaluation and management of childhood pneumonia.

It is our hope that this recent update will assist and guide clinicians in the management o f pCAP
thereby improving the quality of health care for Filipino children.

Mary Therese M. Leopando, MD FPPS FPAPP


President
Philippine Academy of Pediatric Pulmonologists, Inc.

4
INTRODUCTION
Similar to the 2008 and 2012 PAPP Updates in Pediatric Community-acquired Pneumonia, the 2016 PAPP
Update is anchored on a framework that is primarily intended for individual clinical practice. In reviewing the
current body of evidence, such framework has focused on identifying clinically important outcomes for each
clinical question, and expressing the impact of harm and benefit of each intervention in numerical values
whenever possible. While the former is universal, the latter can be applied on a case-to-case basis irrespective of
recommendation.

Three limitations of the current update have to be mentioned. First, because of limited funding and logistics, there
is failure to include cost-benefit ratio of each diagnostic, therapeutic or preventive intervention [which is important
considering that most financial transactions are out-of-pocket in most resource-limited situations]. There is similar
failure to address the issue of availability of interventions in the local setting [which is equally important
considering that some of these are only available in selected medical centers nationwide]. Second, there is a
considerable lack of epidemiologic data, and patient-outcome oriented and knowledge-gap directed body of
researches reported in the local setting, both of which could have provided basis for stronger recommendations.
And third, there is currently no neutral national clearing house outside of PAPP that could have provided initial
guidance and subsequent peer review in developing the guideline update.
th
In preparation for the 4 PAPP Update [2020], these limitations, which potentially can lead to barriers in
Implementation, have to be addressed to narrow the policy-practice gap among local practitioners.
nd rd
Key differences between the 2 and 3 Updates are summarized below.
SECTION KEY DIFFERENCES
2012 2016
A. Methodology
1. Microbial etiology Virus, bacteria and Mtb Virus and bacteria
2. Geographic distribution of
MetroManila MetroManila, MetroCebu and MetroDavao
Task force membership
3. Literature review Jan 2008 to Dec 2011 Jan 2012 to Dec 2016
4. Definition of level of Based on Sacket DL,
evidence and grading Straus SE: Evidence Developed by the 2016 PAPP Task Force in pCAP
of recommendation Based Medicine 2000
5. Geographic distribution of MetroManila Nationwide
stakeholders
B. Summary recommendations
1. Appraisal
1. Predictors to detect radiographic pneumonia
a. Higher threshold for Sa02
Clinical Question1 b. Additional indeces
2. Addition of negative predictors for radiographic pCAP
3. Revised indications for requesting chest xray at initial
site-of-care
Clinical Question 2 No significant change
Clinical Question 3 No significant change
Clinical Question 4 1. Addition of lung ultrasound and anaerobic culture
as diagnostic tests
2. Removal of diagnostic test for tuberculosis
Clinical Question 5 1. Additional test to determine necessity of antibiotic
administration
2. No recommendation for pCAP A or B
2. Therapeutic approach
Clinical Question 6 No significant change
Clinical Question 7 Addition of zanamivir
Clinical Question 8 Addition of deifinition of clinical stability
Clinical Question 9 No significant change
Clinical Question 10 No significant change
Clinical Question 11 Zinc may be beneficial
3. Preventive strategies
Clinical Question 12 Zinc may not be beneficial

Cristan Q. Cabanilla, MD FPAPP FPPS


Chair
2016 PAPP Task Force on pCAP

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METHODOLOGY OVERVIEW
A. Scope
The 3rd PAPP Update in the Evaluation and Management of Pediatric Community-acquired Pneumonia [2016]
is limited to clinical recognition of radiographic community-acquired pneumonia, identification of appropriate
and practical diagnostic procedures, and initiation of rational management and preventive measures in an
immunocompetent patient aged 3 months to 19 years. It does not include recurrent, persistent, aspiration or
ventilator-associated pneumonia, and infection caused by tuberculosis, parasite, fungus or etiologic agent
acquired from a healthcare facility.

B. Intended target users


The intended users are medical practitioners involved in the care of patients with community-acquired pneumonia.

C. Technical Working Group


A technical working group has been designated by the PAPP 2016 Task Force on pCAP t o search for relevant
literature, appraise clinical evidence, and formulate recommendations.

D. Conflict of interest
The following have been resource speakers in continuing medical education activities dealing with pediatric
community-acquired pneumonia sponsored by a pharmaceutical company, a medical society, or a hospital
facility: Vivian A. Ancheta, Gari D. Astrologio, Janet C. Bernardo, Alfredo L. Bongo, Janet Myla Q. Bonleon,
Cristan Q. Cabanilla, Lydia K. Chang, Edward A. Chua, Julie Iris C. Clapano, Amelia G. Cunanan, Beverly D.
de la Cruz, Anjanette R. de Leon, Yadnee V. Estrera, Jean Marie E. Jamero, Arnold Nicholas T. Lim, Grace V.
Malayan, Beatriz Praxedez Apolla I. Mandanas, Raymund Anthony L. Manuel, Vicente Carlomagno D.
Mendoza, Doris Louise C. Obra, Catherine S. Palaypayon, Cynthia Theresa M. Rimando, Emily B. Gaerlan-
Resurreccion, Ernesto Z. Salvador, Marion O. Sanchez, Josy Naty M. Venturina, Rozaida R. Villon, Nilyn
Elise O. Ygnacio, and Dahlia L. Yu.

E. Clinical questions pertaining to evaluation, treatment and prevention


The Task Force has decided to maintain the same clinical questions that were formulated in the 2004 Clinical
Practice Guideline in the Evaluation and Management of Pediatric Community-acquired Pneumonia, 2008
st nd
PAPP 1 Update, and 2012 PAPP 2 Update in the Evaluation and Management of Pediatric Community-
acquired Pneumonia, except clinical questions 8 and 9. The scope of both questions has become broader to
include viral pneumonia.
1. Who shall be considered as having community-acquired pneumonia?
2. Who will require admission?
3. What diagnostic aids are initially requested for a patient classified as either pCAP A or pCAP B being
managed in an ambulatory setting?
4. What diagnostic aids are initially requested for a patient classified as either pCAP C or pCAP D being
managed in a hospital setting?
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 current therapeutic management?
9. What should be done if a patient is not responding to the current therapeutic management?
10. When can switch therapy in bacterial pneumonia be started?
11. What ancillary treatment can be given?
12. How can pneumonia be prevented?

F. Literature search, and inclusion and appraisal of evidence


Local researches submitted to the Philippine Pediatric Society [PPS] and published at the Abstracts Philippine
Pediatric Researches 2012-2015, Philippine Academy of Pediatric Pulmonologists [PAPP], and Pediatric Infectious
Disease Society of the Philippines [PIDSP] Journal, and foreign literature identified using the PubMed database were
searched and limited to the following: [1] source of data from January 1, 2012 to December 31, 2015; [2] 3 months to
19 years of age; and [3] immunocompetent host. Relevant clinical practice guidelines in children and studies in the
adult population were reviewed but not used as evidence for recommendation. Systematic reviews, review articles,
commentaries, a n d case reports or series were excluded. Publication bias potentially existed as published local
articles other than what had been submitted to PPS, PAPP and PIDSP Journal, and unpublished local or foreign
articles were not searched.
Appraisal of evidence and interpretation of results were done based on Dans AL, Dans LF, Silvestre MAA:
Painless Evidence-Based Medicine 2008, England John Wiley and Sons & Ltd.

6
G. Reporting of results of studies in the Summary of Evidence
The results of studies as reported in the Summary of Evidence are outlined to include subject population, study
design, an endpoint considered to be clinically important by the 2016 Task Force to the practitioner,
and numerical result.

H. Grade recommendation with description of level of evidence


Starting with the 2016 Third PAPP Update, The Task Force developed a grading of recommendation supported
by corresponding levels of evidence, as follows:
GRADE RECOMMENDATION STATEMENT DESCRIPTION OF EVIDENCE
A1 Should [or should not] be recommended1 . Definite evidence for benefit [or without benefit] based on at least 1 meta-
A analysis of descriptive or randomized controlled trials, or at least 2 separate
A2 Strong evidence exists to [or not to] be descriptive or randomized controlled trials, with similar intervention, study
recommended but with reservation2. design, outcome AND result.
B1 May [or may not ] be recommended. Equivocal evidence for benefit [or without benefit] based on multiple meta-
B May [or may not] be recommended but with analysis of descriptive or randomized controlled trials, or at least 2 separate
B2 descriptive or randomized trials with dissimilar intervention, outcome, study
reservation2.
design OR results.
C1 May [or may not] be recommended.
Evidence for benefit [or without benefit] based on only one descriptive or
C May [or may not] be recommended but with
C2 randomized controlled trial.
reservation2.
Evidence for benefit [or without benefit] based on consensus opinion of at
D May [or may not] be recommended. least three-fourths of committee members of each clinical question
1
Recommendation as a routine [or not a routine] intervention.
2
Conditional recommendation. Evidence exists BUT with reservations to recommend as to cost, availability, or a consensus among
the members of the Task Force that more similar studies are needed before an appropriate recommendation can be made.

I. Stakeholder’s consultation
Results of questionnaire surveys on pCAP among participants of the PAPP annual convention from 2012-2015
were reviewed and taken into consideration in developing the current guideline.
In addition, a preliminary draft was sent to the following medical stakeholders [who were preselected by the
Task Force] for individual evaluation as to clarity, acceptability and applicability in individual clinical practice:
Philippine Pediatric Society board-certified pediatrician [generalist, infectious disease and ambulatory], general
medical practitioner, rural health physician, pediatric radiologist, pathologist, and postgraduate trainee in
general pediatrics. Gratitude is extended to the following stakeholders for reviewing the document and
providing invaluable comments: Marjorie Grace M. Apigo, Genevieve G. Arenilo, Joseph I. Brazal, Marie Aimee
Hyacinth V. Bretaña, Elia P. Cabrera, Ma. Theresa L. Carin. Jan Kamille R. Coronel, Eva D. de Leon, Angelo
Don S. Grasparil II, Anna Samantha D. Imperial, Jonathan G. Lim, Jo-anne J. Lobo, Marian Carmela B. Magno,
Angel Andrea M.Mendoza, Arcelin L. Piramide, Merfelito B. Ramolete, Yvonne B. Redoble, Maria Leah C.
Rivera, Maja Kristina J. Ruiz, Jaime A. Santos, Maria Araceli F. Torrenueva, and Belinda B. Ycong.
Any opinion expressed by the individual stakeholder did not necessarily reflect that of the medical society or
institution he/she is affiliated with.

J. Formulation of the final draft


At least three-fourths of the members of the Task Force met through teleconferencing, and voted unanimously
for each recommendation. Any disagreements on any recommendation were resolved by votation of at least
three-fourths of all members.

K. Approval by the 2016-2017 PAPP Board of Directors


The final draft was approved by....

L. Source of funding
Internal funding was provided by the Philippine Academy of Pediatric Pulmonologists, Inc. There were no
sources for external funding.

M. Dissemination and periodic evaluation


Dissemination is through the Philippine Academy of Pediatric Pulmonologists [PAPP]. Digital version can be
downloaded free at the PAPP website for a limited time, while a hard copy is available at the PAPP office.
Future periodic evaluation using a questionnaire survey looking at [1] acceptability by the end-user, [2]
utilization in clinical practice, and [3] identification of gaps in knowledge will be done each year by the PAPP
Task Force on pCAP, and distributed to clinicians attending the PAPP Annual Convention. Results of the
th
periodic evaluation will be used for formulating the 4 PAPP Update in the Evaluation and Management of
Pediatric Community-acquired Pneumonia [2020].

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DISCLAIMER

The recommendations presented in this update are limited to options in the evaluation,
management and prevention of community-acquired pneumonia in an immunocompetent
patient aged 3 months to 19 years. Each recommendation should not be presumed to be
applicable to all patients. It is meant to complement but never replace individual clinical
judgement.

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3rd PAPP GUIDELINE UPDATE RECOMMENDATIONS [2016]

IN

PEDIATRIC COMMUNITY-ACQUIRED PNEUMONIA

Clinical Questions

Subcommittee Members

Background: 2nd PAPP Update [2012] Recommendations

3rd PAPP Update [2016] Recommendations

Summary of Evidence

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Clinical Question 1. WHO SHALL BE CONSIDERED AS HAVING COMMUNITY-ACQUIRED PNEUMONIA?

SUBCOMMITTEE MEMBERS
Anjanette R. de Leon
Vicente Carlomagno D. Mendoza
Josy Naty M. Venturina

BACKGROUND
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT*
1. The presence of pneumonia may be considered even without a chest radiograph in a patient presenting with cough and/or
respiratory difficulty [Recommendation Grade D] plus any of the following predictors of radiographic pneumonia:
1.1. At the Emergency Room as the site-of-care,
1.1.1. tachypnea as defined by World Health Organization in a patient aged 3 months to 5 years [Recommendation Grade B]; or
1.1.2. fever at any age [Recommendation Grade B]; or
1.1.3. oxygen saturation < 92% at room air at any age [Recommendation Grade B] in the absence of any coexisting illness
(neurologic, musculoskeletal, or cardiac condition) that may potentially affect oxygenation [Recommendation Grade D].
1.2. At the Out-Patient Clinic as the site-of-care,
1.2.1. tachypnea as defined by World Health Organization in a patient aged 3 months to 5 years [Recommendation Grade D]; or
1.2.2. fever at any age [Recommendation Grade D].
2. The presence of pneumonia should be determined using a chest radiograph in a patient presenting with
2.1. cough and/or respiratory difficulty [Recommendation Grade D] in the following situations:
2.1.1. presence of dehydration aged 3 months to 5 years [Recommendation Grade B].
2.1.2. presence of severe malnutrition aged less than 7 years [Recommendation Grade B].
2.2. high grade fever and leukocytosis aged 3 to 24 months without respiratory symptoms [Recommendation Grade C].

2016 KEY RECOMMENDATIONS**


1. A patient presenting initially with cough and/or respiratory difficulty may be evaluated for possible
presence of pneumonia [Recommendation Grade B2].
1.1. Pneumonia may be considered if any of the following positive predictors of radiographic
pneumonia is present.
At the Emergency Room as the site-of-care.
1.1.1. Oxygen saturation less than or equal to 94% at room air in a patient aged 3 months to 5 years
[Recommendation Grade B2], and above 5 years old [Recommendation Grade C2] in the absence of any comorbid
neurologic, musculoskeletal or cardiac conditions that may potentially affect oxygenation
[Recommendation Grade D].
1.1.2. Tachypnea [age-specific as defined by World Health Organization [WHO] in a patient
aged 3 months to 5 years [Recommendation Grade B2], and above 5 years old [Recommendation Grade D].
1.1.3. Chest wall retractions in a patient aged 3 months to 5 years [Recommendation Grade B2], and
above 5 years old [Recommendation Grade D].
1.1.4. Fever [Recommendation Grade B2], grunting, wheezing, decreased breath sounds, nasal flaring,
cyanosis, crackles or localized chest findings at any age [Recommendation Grade C2].
1.1.5. Consolidation as visualized in lung ultrasound [Recommendation Grade B2].
At the Out-Patient Clinic as the site-of-care.
1.1.6. Oxygen saturation less than or equal to 94% at room air in the absence of any comorbid neu-
rologic, musculoskeletal or cardiac conditions that may potentially affect oxygenation; tachypnea
[age-specific as defined by WHO]; chest wall retractions; fever; decreased breath sounds; nasal
flaring; cyanosis; crackles; or localized chest findings at any age [Recommendation Grade D].
1.2. Pneumonia may not be considered if any of the following negative predictors of radiographic
pneumonia is present.
At the Emergency Room as the site-of-care.
1.2.1. Oxygen saturation greater than 94% at room air in a patient aged 3 months to 5 years
[Recommendation Grade C2], and above 5 years old [Recommendation Grade D].
1.2.2. Absence of fever, nasal flaring and chest wall retractions in a patient aged 3 months to
5 years [Recommendation Grade C2], and above 5 years old [Recommendation Grade D].
At the Out-Patient Clinic as the site-of-care.
1.2.3. Oxygen saturation greater than 94% at room air, and absence of fever, nasal flaring or
chest wall retractions [Recommendation Grade D].
2. Chest x-ray may be requested to determine the presence of pneumonia in any of the following situations:
2.1. Dehydration in a patient aged 3 months to 5 years [Recommendation Grade C2].
2.2. High index of clinical suspicion [Recommendation Grade D].

*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of current grading of recommendation.

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SUMMARY OF EVIDENCE
1. Reference standard
nd
The 2016 PAPP Task Force on pCAP has retained the position statement of the 2012 PAPP 2 pCAP Update,
that chest x-ray is the reference standard in establishing the presence [or absence] of pneumonia. The Task
Force similarly acknowledges the limitations of chest x-ray as a diagnostic tool. There are no studies evaluating
its accuracy in comparison with microbiology as the gold standard. In addition, moderate reliability exists as to
interobserver variability in radiographic interpretation [Neuman M,2012].

2. Initial presentation
The Task Force has retained the position statement of the 2012 Update that a patient presenting initially with
symptoms of cough and/or respiratory difficulty may be evaluated for possible presence of pneumonia. Using
this presentation, the potential risk for the presence or absence of radiographic pneumonia is shown below.
PATIENTS RADIOGRAPHIC PNEUMONIA
INITIAL PRESENTATION AGE AUTHOR/YEAR
[n] Positive Negative
Emergency room as the site of care
Cough or difficulty of breathing 147 58% 42% Modi P,2013
Cough or difficulty of breathing <5y
and --- Wingerter S,2012
324 34%
WHO-defined, age-specific tachypnea

3. Predictors of pneumonia with chest x-ray as the reference standard


3.1. Positive predictors
POSITIVE p
PREDICTOR PATIENTS AGE ODDS RATIO SPECIFICITY PREDICTIVE VALUE AUTHOR / YEAR
[n] [95%CI] VALUE
Emergency room as site-of-care
1
Oxygen saturation
<90% 147 <5y 68% Modi P,2013
<92% 126 6m-18y 0.01 Muthukrishnan L,2013
<94% 3,204 1m-5y 5.90 (3.55-9.80) Nijman R,2013
Clinical presentation
Difficulty of breathing 165 1-16y 63% Alagadan S,2015
Tachypnea
[WHO-defined, age-specific] 147 <5y 72% Modi P,2013
Tachypnea 3,204 1m-5y Nijman R,2013
[PALS cut-off, age specific] 1.55 (0.99-2.42)
147 <5y 8-11% Modi P,2013
Chest wall retractions
3,204 1m-5y 2.11 (1.35-3.32) Nijman R,2013
147 <5y 6% Modi P,2013
Fever
126 6m-18y 0.006 Muthukrishnan L,2013
Grunting 100%
Wheezing 40%
147 <5y Modi P,2013
Decreased breath sounds 38%
Nasal flaring 18%
Cyanosis 5%
Localized chest findings 126 6m-18y 0.001 Muthukrishnan L,2013
2
Predictive score
>9 300 3m–5y 95.7% Arquiza T,2013
(87.2%–98.9%)
Emergency room or ward as site-of-care
3
Lung ultrasound
Consolidation 765 <18y 84% (80%–88%) Pereda M,2015
Outpatient clinic as site-of-care
Risk predictive score2
> 35.8 120 3m-5y 100% Domingo E, 2013
1
Determination of oxygen saturation at room air is desirable in situation where pulse oximeter is available.
2
Unlike the individual parameters which have been mentioned in previous literature, these corresponding predictive scores have
been only recently submitted to the Philippine Pediatric Society and Philippne Academy of Pediatric Pulmonolgists. It is the
consensus among the Task Force members that more studies are needed to assess their reliability and applicability in varying
clinical settings. As such, no definite recommendations using predictive scoring system can be given at this point in time.
3
Subgroup meta-analysis. Advantages of lung ultrasound as an alternative to chest radiograph in patients include detection of pleural
effusion at site-of-care where chest x-ray is not readily available, or in a situation where legal guardians want to avoid ionizing
radiation.The main disadvantage is that it is operator dependent.

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3.2. Negative predictors
PATIENTS
PREDICTOR AGE SENSITIVITY AUTHOR/YEAR
[n]
Emergency room as site-of-care
1
Oxygen saturation
<94% 86%
Clinical presentation
Fever 93%
Nasal flaring 91%
Chest wall retractions 147 <5y 81-85%
Modi P,2013
Decreased breath sounds 70%
Wheezing 44%
Grunting 40%
Tachypnea
37%
[WHO defined. age-specific]
Emergency room or ward as site-of-care
2
Lung ultrasound
Consolidation 765 <18y 96% (94%–98%) Pereda M,2013
1
Determination of oxygen saturation at room air is desirable in situation where pulse oximeter is available.
2
Subgroup meta-analysis. Advantages of lung ultrasound as an alternative to chest radiograph in patients include detection of pleural
effusion at site-of-care where chest x-ray is not readily available, or in a situation where legal guardians want to avoid ionizing
radiation. The main disadvantage is that it is operator dependent.

4. Specific clinical situation in which chest x-ray is needed


Impact of metabolic derangement on clinical predictor of radiographic pneumonia
ODDS RATIO
CLINICAL PREDICTOR
FOR CLINICAL PREDICTOR
METABOLIC DERANGEMENT PATIENTS AGE OF
OF RADIOGRAPHIC AUTHOR/YEAR
STUDY DESIGN [n] RADIOGRAPHIC
PNEUMONIA PNEUMONIA
[CI 95%]
Emergency room as site-of-care
Diarrhea with hypokalemia
180 0-59m Tachypnea 0.36 [0.17-0.34] p=0.005 Chisti M,2013
Prospective cohort

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Clinical Question 2. WHO WILL REQUIRE ADMISSION?

SUBCOMMITTEE MEMBER
Rozaida R. Villon

BACKGROUND
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT*
1. Revised risk classification for pneumonia-related mortalitya [Recommendation Grade D]
CLASSIFICATION PROVIDED BY
PhilippineAcademy of Pediatric Pulmonologists, Inc pCAP A or B pCAP C pCAP D
Philippine Health Insurance Corporation --- Pneumonia I Pneumonia II
World Health Organization Nonsevere Severe Very severe
b
VARIABLES
Clinical
1. Dehydrationc None Mild Moderate Severe
2. Malnutritiond None Moderate Severe
3. Pallor None Present Present
e
4. Respiratory rate a. 3 to12 months >50/min to <60/min >60/min to <70/min >70/min
b. 1 to 5 yearse >40/min to <50/min >50/min >50/min
c. >5 years >30/min to <35/min >35/min >35/min
5. Signs of respiratory failure a. Retraction None Intercostal / subcostal Supraclavicular / IC / subcostal
b. Head bobbing None Present Present
c. Cyanosis None Present Present
d. Grunting None None Present
e. Apnea None None Present
f. Sensorial changes None Irritable Lethargic / stuporous / comatose
f
Diagnostic aid at site-of-care
1. Chest x-ray findings of any of the following: effusion; None Present Present
abscess; air leak or lobar consolidation
2. Oxygen saturation at room air using pulse oximetry 95% <95% <95%
ACTION PLAN
1. Site-of-care Outpatient Admit to ward Admit to a critical care facility
2. Follow-up End of treatment
a
In order to classify to a higher risk category, at least 2 variables (clinical and diagnostic aid) should be present. In the absence of a diagnostic aid variable, clinical variables will suffice.
b
Risk factors for mortality based on evidence and/or expert opinion among members of the 2012 PAPP Task Force on pCAP.
c
Weight for Height SD score< -2 moderate; SD score< -3 severe. WHO management of severe malnutrition: a manual for physicians and other health workers. Geneva. WHO 1999.
d
Grading of dehydration adapted from Nelson’s Textbook of Pediatrics: MILD [thirsty, normal or increased pulse rate, decreased urine output and normal physical examination];
MODERATE [tachycardia, little or no urine output, irritable/lethargic, sunken eyes and fontanel, decreased tears, dry mucus membranes, mild tenting of the skin, delayed capillary
refill, cool and pale]; SEVERE [rapid and weak pulse, decreased BP, no urine output, very sunken eyes and fontanel, no tears, parched mucous membranes, tenting of the skin, very
delayed capillary refill, cold and mottled].
e
World Health Organization age-specific criteria for tachypnea for children under 5 years old.
f
Chest x-ray and pulse oximetry are desirable variables but not absolutely necessary as determinants of admission at site-of-care.

2. Patients under 5 years old [Recommendation Grade B] and more than 5 years old [Recommendation Grade D] 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.

2016 KEY RECOMMENDATIONS**


1. A patient may be classified as pCAP A, B, C or D within 48 hours after consultation based on the
following risk classification for pneumonia-related mortality [Recommendation Grade D].
PARAMETERS IDENTIFIED RISK CLASSIFICATION1
AT pCAP A pCAP B pCAP C pCAP D
INITIAL SITE-OF-CARE Nonsevere Severe or moderate risk Very severe or high risk
Clinical parameters2
1. Respiratory signs
1.1. Retraction None Intercostal / subcostal Supraclavicular / IC / subcostal
1.2. Head bobbing None Present Present Present
1.3. Cyanosis None None Present
1.4. Grunting None None Present
1.5. Apnea None Present
1.6. Tachypnea >60/min to <70/min
3
1.6.1. 3 to12 months >50/min to <60/min >50/min >70/min
1.6.2. 1 to 5 years3 >40/min to <50/min >35/min >50/min
1.6.3. >5 years >30/min to <35/min >35/min
1
In order to classify to a higher risk category, at least 2 parameters [clinical and/or ancillary] may be present. In the absence of
an ancillary parameter, clinical parameters may suffice.
2
Risk factors for mortality based on evidence and/or expert opinion among members of the 2016 PAPP Task Force on pCAP.
3
World Health Organization age-specific criteria for tachypnea for children under 5 years old.

*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of current grading of recommendation.

13
2. Central nervous system signs
2.1. Altered sensorium None Irritable Lethargic / stuporous / comatose
2.2. Convulsion None Present Present
3. Circulatory signs
3.1. Poor perfusion None Capillary refill >3s Shock
3.2. Pallor None Present Present
4. General considerations
4.1. Malnutrition4 None Mild No Moderate Severe
4.2. Inability to drink No Present Yes Yes
4.3. Comorbid conditions None Present Present
Ancillary parameters5
5. Chest x-ray findings of effusion,
abscess, air leak or multilobar None Present Present
consolidation
6. Oxygen saturation at room air using
95% 91% to 94% <90%
pulse oximetry
4
Weight for Height [WFH] SD score < -2 moderate; SD score < -3 severe. WHO management of severe malnutrition: a manual for
physicians and other health workers. Geneva. World Health Organization 1999.
5
Chest x-ray and pulse oximetry are desirable variables but not necessary as determinants of admission at site-of-care.
2. A patient initially classifed as pCAP A or B but is not responding to current treatment after 48 hours may
be admitted [Recommendation Grade D].
3. A patient classified as pCAP C may be
3.1. admitted to the regular ward [Recommendation Grade D].
3.2. managed initially on an outpatient basis [Recommendation Grade C2] if all of the following are not
present at initial site-of-care [Recommendation Grade D].
3.2.1. Age less than 2 years old.
3.2.2. Convulsion.
3.2.3. Chest x-ray with effusion, lung abscess, air leak or multilobar consolidation.
3.2.4. Oxygen saturation < 95% at room air.
4. A patient classified as pCAP D may be admitted to a critical care unit [Recommendation Grade D].

SUMMARY OF EVIDENCE
1. Risk classification scheme
The Task Force has maintained the previous risk classification scheme for pneumonia-related mortality from the
PAPP 2012 Clinical Practice Guideline in the Evaluation and Management of pCAP with minor modifications.

2. Individual risk factors for subsequent mortality within 48 hours at initial site-of-care.
STUDY DESCRIPTION ODDS RATIO P
RISK FACTORS n/N [%] AUTHOR/YEAR
DESIGN AGE [95%CI] VALUE
1
49/85 [57.6%] 1.85 (1.03-3.32) 0.020 Ramachandran P,2012
Severe malnutrition 1.91 (0.67–4.92) 0.230 Agweyu A,2014
1.37 (0.35–5.31) Webb C, 2012
22/85 [25.9%] 14.49 (4.49-51.88) 0.001 Ramachandran P,20121
Altered consciousness
1.02 (0.40–2.59) 0.970 Agweyu A,2014
<59m 11.15 (3.38-40.59) 0.001 Ramachandran P,20121
Convulsion
6.83 (2.01–23.2) Webb C 2012
1
Cohort 1 to 6m 49/85 [57.7%] 2.77 (1.57-4.91) 0.001 Ramachandran P,2012
Age
2 to11m 1.80 (0.57–5.67) 0.310 Agweyu A,2014
Shock 9.99 (3.36–29.7) Webb C,2012
4/85 [4.7%] 0.51 (0.14-1.72) 0.230 Ramachandran P,20121
2
<12y Increasing severity 3.20 (1.20-8.90) 0.020 Ferreira S,2014
Inability to drink 6.39 (1.40–29.23) 0.006 Agweyu A,2014
1
Congenital heart disease 10/85 [11.8%] 5.53 (1.53-21.72) 0.001 Ramachandran P,2012
Head nodding 2.15 (0.84–5.50) 0.100
<59m Central cyanosis 1.85 (0.56–6.08) 0.300 Agweyu A,2014
Grunting 0.71(0.27–1.86) 0.490
SpO2 <90% 0.31 (0.07–1.42) 0.110
1 2
Radiologic pneumonia cases Multivariate analysis
3. Composite risk factors for subsequent mortality within 48 hours at initial site-of-care
This is a gap in current knowledge. There are no published data available for review.
4. Management of pCAP C on an outpatient basis
STUDY DESCRIPTION MORTALITY TREATMENT FAILURE RATE
INTERVENTION AUTHOR/YEAR
DESIGN AGE RATE AT DAY 14
7 days oral amoxicillin at home 0.2% [1/554] 10.8% (60/554)
RCT <59m vs vs Patel A,2015
vs
7 days oral amoxicillin for 48 hours at
hospital followed by 5 days at home 0.2% [1/564] 18.1% (102/564)

14
Clinical Question 3. WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT
CLASSIFIED AS EITHER pCAP A or pCAP B BEING MANAGED IN AN AMBULATORY SETTING?

SUBCOMMITTEE MEMBER
Marion O. Sanchez

BACKGROUND
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT.*
1. Chest x-ray may be requested to rule out pneumonia-related complications or pulmonary conditions simulating pneumonia
[Recommendation Grade D].
1.1. It should not be routinely requested to predict end-of-treatment clinical outcome [Recommendation Grade A].
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 [Recommendation Grade D].

2016 KEY RECOMMENDATIONS**


1. The following may be requested at initial site-of-care
Clinically important endpoint: assessment of gas exchange
1.1. Oxygen saturation using pulse oximetry [Recommendation Grade D].
Clinically important endpoint: microbial determination of underlying etiology
1.2. Gram stain and/or aerobic culture and sensitivity of sputum [Recommendation Grade D]
Clinically important endpoint: clinical suspicion of necrotizing pneumonia, multilobar consolidation,
lung abscess, pleural effusion, pneumothorax or pneumomediastinum
1.3. Chest x-ray PA-lateral [Recommendation Grade D]
1.4. Chest ultrasound [Recommendation Grade D]
2. The following may not be requested.
Clinically important endpoint: microbial determination of underlying etiology
2.1. Blood culture and sensitivity [Recommendation Grade D]
Clinically important endpoint: basis for initiating antibiotic treatment
2.2. White blood cell [WBC] count [Recommendation Grade D]
2.2. C-reactive protein [CRP] [Recommendation Grade D]
2.4. Procalcitonin [PCT) [Recommendation Grade D]

SUMMARY OF EVIDENCE
Gap in knowledge. There are no published studies available for review.

*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of current grading of recommendation.

15
Clinical Question 4. WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT
CLASSIFIED AS EITHER pCAP C or pCAP D BEING MANAGED IN A HOSPITAL SETTING?

COMMITTEE MEMBER
Cristan Q. Cabanilla

BACKGROUND.
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT*
1. For pCAP C,
1.1. The following ancillary/diagnostic procedures should be done.
1.1.1. To assess gas exchange
1.1.1.1. Oxygen saturation using pulse oximetry [Recommendation Grade D]
1.1.1.2. Arterial blood gas [Recommendation Grade D]
1.1.2. To determine etiology
1.1.2.1. Gram stain and/or culture and sensitivity of pleural fluid when available [Recommendation Grade D]
1.2. The following ancillary/diagnostic procedures may be done
1.2.1. To confirm clinical suspicion of multilobar consolidation, lung abscess, pleural effusion, pneumothorax or pneumomediastinum
1.2.1.1. Chest x-ray PA-lateral [Recommendation Grade D]
1.2.2. To determine appropriateness of antibiotic usage
1.2.2.1. C-reactive protein (CRP) [Recommendation Grade A]
1.2.2.2. Procalcitonin (PCT) [Recommendation Grade B]
1.2.2.3. Chest x-ray PA-lateral [Recommendation Grade C]
1.2.2.4. White Blood Cell (WBC) count [Recommendation Grade D].
1.2.2.5. Gram stain of sputum or nasopharyngeal aspirate [Recommendation Grade D]
1.2.3. To determine etiology
1.2.3.1. Sputum culture and sensitivity [Recommendation Grade C]
1.2.3.2. Blood culture and sensitivity [Recommendation Grade C]
1.2.4. To predict clinical outcome
1.2.4.1. Chest x-ray PA-lateral [Recommendation Grade B]
1.2.4.2. Pulse oximetry [Recommendation Grade B]
1.2.5. To determine the presence of tuberculosis if clinically suspected
1.2.5.1. Mantoux test (PPD 5-TU) [Recommendation Grade D]
1.2.5.2. Sputum smear for acid-fast bacilli [Recommendation Grade D]
1.2.6. To determine metabolic derangement
1.2.6.1. Serum electrolytes [Recommendation Grade C]
1.2.6.2. Serum glucose [Recommendation Grade C]
2. For pCAP D, a referral to a specialist should be done [Recommendation Grade D]

2016 KEY RECOMMENDATIONS**


1. For pCAP C and pCAP D, the following diagnostic aids may be requested at initial site-of-care.
Clinically important endpoint: assessment of gas exchange
1.1. Oxygen saturation using pulse oximetry [Recommendation Grade D]
1.2. Arterial blood gas [Recommendation Grade D]
Clinically important endpoint: Surrogate markers for possible presence of pathogens requiring initial
empiric antibiotic with microbiology as the reference standard
1.3. C-reactive protein [CRP] [Recommendation Grade B1]
1.4. Procalcitonin [PCT] [Recommendation Grade B1]
1.5. Chest x-ray PA-lateral [Recommendation Grade C2]
1.6. White blood cell [WBC] [Recommendation Grade C2]
Clinically important endpoint: clinical suspicion of necrotizing pneumonia, multilobar consolidation,
lung abscess, pleural effusion, pneumothorax or pneumomediastinum.
1.7. Chest x-ray PA-lateral [Recommendation Grade C1]
1.8. Chest ultrasound [Recommendation Grade B2]
Clinically important endpoint: determination of underlying microbial etiology
1.9. Gram stain and/or aerobic culture and sensitivity of sputum, nasopharyngeal aspirate and/or
pleural fluid, and/or blood for pCAP C with lung abscess, empyema or pneumothorax
[Recommendation Grade C1]
1.10. Gram stain and/or aerobic culture and sensitivity of sputum, tracheal aspirate and/or pleural fluid, for
pCAP D [Recommendation Grade D]
1.11. Anaerobic culture and sensitivity of sputum, nasopharyngeal aspirate, pleural fluid, and/or blood
culture and sensitivity for [Recommendation Grade D]
1.11.1. pCAP C with lung abscess, empyema or pneumothorax
1.11.2. pCAP D
1.12. Serum IgM for Mycoplasma pneumoniae [Recommendation Grade B2]
*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation.

16
Clinically important endpoint: determination of metabolic derangement for immediate correction on admission
1.13. pH in arterial blood gas for metabolic acidosis [Recommendation Grade C2]
1.14. Serum sodium for hyponatremia [Recommendation Grade B2]
1.15. Serum potassium for hypokalemia [Recommendation Grade C2]
Clinically important endpoint: predictor of clinical outcome
1.16. Predictive marker for mortality
1.16.1. pH in arterial blood gas for metabolic acidosis [Recommendation Grade B1]
1.17. Predictive marker for initial treatment failure
1.17.1. Pulse oximetry for oxygen saturation less than 90% at room air, chest x-ray PA-lateral for
pleural effusion or consolidation, or WBC for leukocytosis or leukopenia [Recommendation Grade B1]
1.17.2. Blood culture for bacteremia, serum hemoglobin for anemia, or serum glucose for
hypoglycemia [Recommendation Grade B2]
1.18. Predictive marker for prolonged hospitalization or pneumatocoele formation
1.18.1. Lung ultrasound showing impaired perfusion and hypoechoic lesions [Recommendation Grade B2]
2. For pCAP D, a referral to a specialist may be done for additional diagnostic tests [Recommendation Grade D]
3. For uncomplicated pCAP C, the following may not be requested.
Clinically important endpoint: determination of underlying microbial etiology
3.1. Blood culture [Recommendation Grade B2]
Clinically important endpoint: prediction of clinical outcome
3.2. CRP as marker for risk of treatment failure or prolonged hospitalization [Recommendation Grade B2].

SUMMARY OF EVIDENCE
1. Clinically important endpoint: surrogate markers for possible presence of pathogens requiring initial empiric
antibiotic with microbiology as the reference standard
DIAGNOSTIC AID : FINDINGS ODDS RATIO YIELD SPECIFICITY
PATHOGEN [95% CI] [%] p VALUE [95% CI] AUTHOR/YEAR
STUDY DESIGN
C-reactive protein [CRP] : >80 mg/L 3.6
Bacterial/atypical vs viral pathogen [1.65–8.07] 0.001 Elemraid M,2014
Prospective cohort
CRP : elevated 19
Pneumococcal vs viral pathogen [5-75] Galetto-Lacour A,2013
Prospective cohort
CRP : elevated
Bacterial vs viral pathogen 0.020 Hoshina T,2014
Retrospective cohort
CRP : > 200 ug/ml
Bacterial pathogen 56.10% Huang H,2014
Case control
CRP : abnormal 30.9%
Mycoplasma p vs non-Mycoplasma p vs 0.002 Gao J,2015
Cross-sectional 23.7%
Procalcitonin [PCT] : elevated 23
Bacterial vs non-bacterial pathogen [5-117] Galetto-Lacour A,2013
Prospective cohort
PCT : elevated
Pneumococcal vs non-bacterial pathogen 0.0008 Hoshina T,2014
Retrospective cohort
Lipocalin 2 : >130.1 ng/ml
Probable bacterial pathogen 85.7% Huang H,2014
Case control
Chest x-ray : pneumonia 93%
Pneumococcal infection Nascimento-Carvalho C,2015
[80-98]
Cross-sectional
IgM assay : 1.65 mean value 96.93%
Mycoplasma pneumoniae [reference std: Medjo B,2014
Cross-sectional RT-PCR]
White blood cell count [WBC] : abnormal 65.5%
Mycoplasma p vs non-Mycoplasma p vs 0.001 Gao J,2015
Cross-sectional 55.2%
WBC : abnormal Not
Bacterial vs non-bacterial pathogen significant Hoshina T,2014
Cohort
WBC : >15 × 109/L 0.5
Bacterial vs viral pathogen 0.320 Elemraid M,2014
[0.13–1.96]
Prospective cohort

17
Neutrophil count : >10 × 109 /L 5.9
Bacterial vs viral pathogen 0.012 Elemraid M,2014
[1.47–23.94]
Prospective cohort
Neutrophil count : abnormal Not
Bacterial vs non-bacterial pathogen significant Hoshina T,2014
Cohort
Neutrophil to lymphocyte ratio : 2.7
Bacterial vs viral pathogen <0.001
Retrospective cohort Bekdas M,2014
CRP to mean platelet volume ratio : 11.0
Bacterial vs viral pathogen <0.001
Retrospective cohort

2. Clinically important endpoint: radiologic evidence of clinical suspicion of necrotizing pneumonia, multilobar
consolidation, lung abscess, pleural effusion, pneumothorax or pneumomediastinum
CONDITION DIAGNOSTIC AID INCIDENCE AUTHOR / YEAR
Chest x-ray 32/882 [3.7%] Krenke K,2015
Necrotizing pneumonia Lung ultrasound 10/140 [7.1%]
Lai S,2015
Lung ultrasound + CT scan 70/96 [72.1%]
3. Clinically important endpoint: determination of underlying microbial etiology
The Task Force recognizes the trade-off between the need to identify microbial etiology and the cost-benefit
ratio in terms of actual yield. There are no local data available for review.
YIELD
SPECIMEN : FINDINGS REMARKS AUTHOR/YEAR
n/N [%, CI 95%]
TECHNIQUE / STUDY DESIGN
PATHOGEN CONTAMINANT
RESPIRATORY SECRETIONS
Induced sputum : +bacteria, Mycoplasma, virus 69/76 Honkinen M,2012
Culture, RT-PCR / Prospective cohort [91%]
Sputum : +bacteria 138/464 Vong S,2013
Culture / Prospective cohort [29.7%]
Nasopharyngeal aspirate : +Mycoplasma p 24/166 Medjo B,2014
RT-PCR / Cross-sectional [14.5%]
Nasopharyngeal aspirate : +Mycoplasma p 38/368 Gotoh K,2012
Loop-med isothermal amp ass / Cross-sectional [10.3%]
Nasopharyngeal aspirate : bacteria, virus 38/45 Chen Y,2012
Multiplex PCR,Quick Ag,culture / Cross-sectional [84.4%]
Lung aspirate and pleural fluid : bacterial 20/57 Howie S,2014
Culture / Cross-sectional [38%]
PLEURAL FLUID
Pleural fluid : +bacteria 79/288 Deceuninck G, 2013
Culture / Retrospective cohort [27.4%]
Pleural fluid : +bacteremia 2/5 Heine D,2013
Culture / Cross-sectional [40.0%]
BLOOD
Blood : +bacteremia CAP: severe vs Iroh Tam P,2015
Culture / Meta-analysis [5.14%,3.61-7.28%] [14.7%] less severe [p=.008]
Blood : +bacteremia 27/862 Vong S,2013
Culture / Prospective cohort [3.1%]
Blood : +bacteremia 18/405 22/405 Chisti M ,2014
Culture / Prospective cohort [4.4%] [5%]
Blood : +bacteremia 0/45 Chen Y,2012
Culture / Prospective cohort
Blood : +bacteremia 2/171 3/171 Lai E,2014
Culture / Prospective cohort [1.2%] [1.8%]
Blood : +bacteremia 2/139 3/139 Parikh K,2014
Culture / Retrospective cohort [1.4%] [2.1%]
Blood : +bacteremia 26/369 7/369 Myers A,2013
Culture / Retrospective cohort [7%, 4.7–10.1%] [1.8%]
Blood : +bacteremia 53/288 With empyema Deceuninck G,2013
Culture / Retrospective cohort [18.4%] thoracis
Blood : +bacteremia 6/390 9/390 McCulloh R,2015
Culture / Retrospective cohort [1.5%] [2.3%]
Blood : +bacteremia 5/155 1/155 Heine D,2013
Culture / Cross-sectional [3.2%] [<1% ]
Blood : +bacteremia 17/329 16/329 Real-time PCR Selva A,2013
Culture / Cross-sectional [5.1%] [4.9%] from dried blood spot
Blood : +bacteremia 2/82 Ybanez S,2014
Culture / Case control [2.4%]
Blood : +Pneumococcal bacteremia 1/73 Complicated pneumo-
Culture / Case control [1.4%] coccal CAP vs control Esposito S,2012
Blood : +Pneumococcal bacteremia 67/73 (p=0.02)
PCR for Streptococcus pneumoniae / Case control [91.8%]

18
4. Clinically important endpoint: number of cases with metabolic derangement
DIAGNOSTIC AID : FINDINGS
n/N [%] REMARKS AUTHOR/YEAR
STUDY DESIGN
Blood pH : metabolic acidosis [total serum CO2 <17 mMol/L] 66/164 Diarrhea as Chisti M,2012
Case control [40.2%] comorbid illness
Blood pH : metabolic acidosis [pH<7.0,HC03<24 mM, anion gap>16 mM] Total number of Wang L, 2013
Case control cases: 21
Serum sodium : soidum <130 mm/L Total number of Consolidation by Glatstein M,2014
Cross-sectional cases: 54 chest xray
Serum sodium : soidum <130 mm/L 104/312 Wrotek A,2013
Cross-sectional [33.3%]
Serum potassium : potassium <3.5 mMol/L 51/180 Diarrhea as Chisti M,2013
Prospective cohort [31%] comorbid illnes

5. Clinically important endpoint: predictor of clinical outcome.


DIAGNOSTIC AID : FINDINGS CLINICAL RR or OR P
REMARKS AUTHOR/YEAR
STUDY DESIGN OUTCOME [95% CI] VALUE
Blood pH : metabolic acidosis Case fatality rate:
[total serum CO2<17 mMol/L] 16% vs 5% 0.039 Chisti M,2012
Case control Mortality Comorbidity : diarrhea
Blood pH : metabolic acidosis 8.50
[pH<7.0,HC03<24 mM, anion gap>16mM] [2.82-25.60] 0.001 Wang L,2013
Case control
ICU 6.6
Chest x-ray : bilateral multilobar infiltrates admission [2.1-14.5]
Retrospective cohort Mechanical 3.0
ventilation [1.2-7.9]
Chest x-ray : unilateral multilobar infiltrates 8.0
Retrospective cohort ICU [2.9, 22.2] McClain L,2014
admission 3.2
Chest x-ray : moderate to large effusion [1.1, 8.9]
Retrospective cohort Mechanical 14.8
ventilation [9.8-22.4]
Chest x-ray : pleural effusion 14.10 0.03 Huang C,2013
Prospective cohort [1.37-145.2]
Chest x-ray : consolidation 0.56 <0.001 Basnet S,2015
Prospective cohort [0.46-0.69]
Pulse oximetry : O2 sat<90% at room air 2.40 0.03 Jain D,2013
Case control [0.80-8.52]
Pulse oximetry : O2 sat <90% at room air 1.91 <0.001 Basnet S,2015
Prospective cohort [1.33-2.74]
White blood cell count : >17,500/mL 2.42 0.03 Huang C,2013
Prospective cohort Initial [1.08-5.45]
White blood cell count : <4000 treatment 1.77
failure 0.06
Case control [0.6-5.7] Jain D,2013
Blood culture : +bacteremia 7.39 0.02
Case control [2.44-22.43]
Hemoglobin : <10 g/dL 2.38 0.05 Huang C,2013
Prospective cohort [1.00-5.67]
Capillary blood glucose : <60 mg/dL 1.33 Jain D,2013
0.14
Case control [0.48-5.29]
C-Reactive protein : >40 mg/L 1.01 0.918 Basnet S,2015
Prospective cohort [0.84-1.21]
Serum sodium : hyponatremia 10.01 Wrotek A,2013
Retrospective cohort
CRP : 7.5 mg/dL [median value] Prolonged 1.03 Williams D,2015
Retrospective cohort hospitalization [1.00-1.04]
3.08
[1.15–8.29]
Lung ultrasonography : impaired perfusion, Pneumatocoele 10.11
hypoechoic lesions with effusion risk [2.95–34.64] Lai S,2015
Retrospective cohort Pneumatocoele
8.28
with subsequent
[1.86–36.93]
surgery

19
Clinical Question 5. WHEN IS ANTIBIOTIC RECOMMENDED?

SUBCOMMITTEE MEMBERS
Cynthia Theresa M. Rimando
Ernesto Z. Salvador

BACKGROUND
nd
2012 2 PAPP UPDATE SUMMARY HIGHLIGHT*
1. For pCAP A or pCAP B, an antibiotic may be administered if a patient is
1.1. beyond 2 years of age [Recommendation Grade D]; or
1.2. with high grade fever without wheeze [Recommendation Grade D].
2. For pCAP C, an antibiotic
2.1. should be administered if alveolar consolidation on chest x-ray is present [Recommendation Grade C].
2.2. may be administered if a patient is with any of the following:
2.2.1. Elevated serum C-reactive protein [CRP] [Recommendation Grade A]
2.2.2. Elevated serum procalcitonin level [PCT] [Recommendation Grade B]
2.2.3. Elevated white cell count [WBC] [Recommendation Grade D].
2.2.4. High grade fever without wheeze [Recommendation Grade D].
2.2.5. Beyond 2 years of age [Recommendation Grade D].
3. For pCAP D, a specialist should be consulted [Recommendation Grade D].

2016 KEY RECOMMENDATIONS**


1. For pCAP C, empiric antibiotic may be started if any of the following is present.
1.1. Elevated
1.2.1. serum C-reactive protein [CRP] [Recommendation Grade B1]
1.2.2. serum procalcitonin level [PCT] [Recommendation Grade B1]
1.2.3. white blood cell [WBC] count [Recommendation Grade B2] greater than 15,000 [Recommendation D]
1.2.4. lipocalin 2 [Lpc-2] [Recommendation Grade B2]
1.2 Alveolar consolidation on chest x-ray [Recommendation Grade B2]
1.3. Persistent high-grade fever without wheeze [Recommendation Grade D]
2. For pCAP D, a specialist may be consulted [Recommendation Grade D]

*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation.

20
SUMMARY OF EVIDENCE
1. Clinically relevant information: epidemiology
1.1. Ambulatory patients
Gap in knowledge. No published data are available for review.
1.2. Hospitalized patients
1.2.1. Gap in knowledge in local literature. No local data are available for review.
1.2.2. Foreign data
POSITIVE YIELD [n] POSITIVE YIELD OF POSITIVE YIELD
COUNTRY PER SAMPLE PATHOGENS1 REQUIRING OF
LABORATORY METHOD AGE INITIAL ANTIBIOTIC VIRAL PATHOGEN AUTHOR
[or SUBJECT] [N] YEAR
n/N [%] THERAPY n/N [%]
n/N [%]
0-16y 806/3181 [25%] 2375/3181 [75%]
0-1y 716/1249 [57%] 1440/2375 [67%]
China 1381/3181 Wei L
Culture, molecular 1-4y 451/1249 [37%] 744/2375 [31%] 2015
4-6y 42/1249 [3%] 92/2375 [4%]
6-16y 40/1249 [3%] 99/237[4%]
Austria 190/279 [68%] Adolescent 83/190 [34%] 107/190 [56%] Kurz H
Culture, molecular Child 2013
China 1613/1613 [100%] Child 678/1613 [42%] 935/1613 [58%]2 Peng Y
Culture 2015
United States 1802/2222 [81%] <18y 330/1802 [18%] 1472/1802 [82%] Jain S
Culture, serology 2015
Niger 138/1691 [8%] <5y 126/138 [91%] Lagare A
102/138 [74%]
Molecular 2015
UK
Culture, molecular, Elemraid M
214/401 [53%] <16y 132/214 [62%] 82/214 [38%] 2013
urine ag test, serology,
immunofluorescence

India 279/2345 <12y 251/279 [90%] 28/279 [10%] Mathew J


Molecular [12%] 2015
Finland 74/76 4.7y Honkinen M
69 /74 [91%] 55/74 [72%]
Culture, molecular [97%] SD +1.9y 2012
Nepal 503/722 <5y 290/503 [58%] 213/503 [42%] Banstola A
Culture [70%] 2013
Taiwan
Culture, urine ag test, 209/245 Chen C
7m-16y 123/209 [59%] 86/209 [41%] 2012
serology, virus isolation, [85%]
immunofluorescence
1
Bacterial or codetection of bacterial and viral pathogens
2
RSV

2. Clinically important endpoint at site-of-care: surrogate markers of bacterial pathogen


2.1. Ambulatory patients
Gap in knowledge. No published data are available for review.
2.2. Hospitalized patients
Gap in knowledge in local literature. No data are available for review.
DIAGNOSTIC AID : FINDINGS ODDS RATIO YIELD p VALUE SPECIFICITY AUTHOR
PATHOGEN [95% CI] [%] [95% CI] YEAR
STUDY DESIGN
C-reactive protein [CRP] : >80 mg/L 3.6 Elemraid M
Bacterial/atypical vs viral pathogen [1.65–8.07] 0.001
2014
Prospective cohort
C-reactive protein : elevated 19 Galetto-Lacour A
Pneumococcal vs viral pathogen [ 5-75] 2013
Prospective cohort
C-reactive protein : elevated Hoshina T
Bacterial vs viral pathogen 0.020 2014
Retrospective cohort
C-reactive protein : abnormal Gao J
Mycoplasma p vs non-Mycoplasma p 30.9 vs 23.7 0.002 2015
Cross-sectional
C-reactive protein : > 200 ug/ml Huang H
Bacterial pathogen 56.10% 2014
Case control

Procalcitonin : elevated 23
Bacterial vs non-bacterial pathogen [5-117] Galetto-Lacour A
Prospective cohort 2013

21
Procalcitonin : elevated Hoshina T
Pneumococcal vs non-bacterial pathoge 0.0008
2014
Retrospective cohort

Lipocalin 2 : >130,1 Huang H


Probable bacterial pathogen 85.7% 2014
Case control

Chest x-ray : presence of pneumonia 93% Nascimento-Carvalho C


Pneumococcal infection [80-98%] 2015
Cross-sectional

White blood cell count : abnormal 65.5% Gao J


Mycoplasma p vs non-Mycoplasma p vs 0.001 2015
Cross sectional 55.2%
White blood cell count : abnormal Not Hoshina T
Bacterial vs non-bacterial pathogen significant 2014
Cohort
White blood cell count : >15 × 109/L 0.5
Bacterial vs viral pathogen 0.320
[0.13–1.96] Elemraid M
Prospective cohort
2014
109/L
Neutrophil count : >10 × 5.9
Bacterial vs viral pathogen 0.012
[1.47–23.94]
Prospective cohort
Neutrophil count : abnormal Not Hoshina T
Bacterial vs nonbacterial pathogen significant 2014
Cohort
Neutrophil to lymphocyte ratio : 2.7
Bacterial vs viral pathogen <0.001
Retrospective cohort Bekdas M
CRP to mean platelet volume ratio: 11.0 2014
Bacterial vs viral pathogen <0.001
Retrospective cohort

22
Clinical Question 6. WHAT EMPIRIC TREATMENT SHOULD BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?

SUBCOMMITTEE MEMBERS
Alfredo L. Bongo Jr
Lydia K. Chang
Edward A. Chua
Arnold Nicholas T. Lim
Doris Louise C. Obra
Nilyn Elise O. Ygnacio
Dahlia L. Yu

BACKGROUND
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT*
1. For a patient who has been classified as pCAP A or pCAP B without previous antibiotic,
1.1. amoxicillin [40-50 mg/kg/day, maximum dose of 1500 mg/day in 3 divided doses for at most 7 days] is the drug of choice
[Recommendation Grade B].
1.1.1. Amoxicillin may be given for a minimum of 3 days [Recommendation Grade A].
1.1.2. Amoxicillin may be given in 2 divided doses for a minimum of 5 days [Recommendation Grade B].
1.2. Azithromycin [10 mg/kg/day OD for 3 days, or 10 mg/kg/day at day 1 then 5 mg/kg/day for days 2 to 5, maximum dose of 500
mg/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 [Recommendation Grade D].
2. For a patient who has been classified as pCAP C, without previous antibiotic,
2.1. requiring hospitalization, and
2.1.1. has completed the primary immunization against Haemophilus influenzae type b, penicillin G [100,000 units/kg/day in 4
divided doses] administered as monotherapy is the drug of choice [Recommendation Grade B].
2.1.2. has not completed the primary immunization or immunization status unknown against Haemophilus influenzae type b,
ampicillin [100 mg/kg/day in 4 divided doses] administered as monotherapy is the drug of choice [Recommendation Grade B].
2.1.3. above15 years of age [Recommendation Grade D], a parenteral non-antipseudomonal β-lactam (β-lactam / β-lactamase
inhibitor combination (BLIC), cephalosporin or carbapenem] + extended macrolide [azithromycin or clarithromycin], or a
parenteral non-antipseudomonal β-lactam [β-lactam/ β-lactamase inhibitor combination (BLIC], cephalosporin or
carbapenem] + respiratory fluoroquinolones [levofloxacin or moxifloxacin] administered as combination therapy may be given
[Recommendation Grade A].
2.2. 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 [Recommendation Grade B].
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 [Recommendation Grade D].
4. For a patient who has been established to have Mycobacterium tuberculosis infection or disease, antituberculous drugs should be
started [Recommendation Grade D].

2016 KEY RECOMMENDATIONS**


1. For a patient who has been classified as pCAP A or pCAP B without previous antibiotic, regardless of the
immunization status against Haemophilus influenzae type b or Streptococcus pneumoniae,
1.1. Amoxicillin trihydrate may be given [Recommendation Grade B1].
1.1.1. It may be given at 40-50 mg/kg/day, maximum dose of 1500 mg/day in 3 divided doses in
areas with proven low antibiotic resistance to amoxicillin [Recommendation Grade D].
1.1.2. It may be given at 90 mg/kg/day in areas with proven high amoxicillin resistance
[Recommendation Grade D].
1.1.3. It may be given for a minimum of 3 days [Recommendation Grade B2].
1.1.4. It may be given in 2 divided doses for a minimum of 5 days [Recommendation Grade B2].
1.2. Azithromycin [10 mg/kg/day OD for 3 days, or 10 mg/kg/day at day 1 then 5 mg/ kg/day for day 2 to 5,
maximum dose of 500 mg/day], or clarithromycin [15 mg/kg/day, maximum dose of 1000 mg/day in 2
divided doses for 7 days] may be given if there is
1.2.1. known hypersensitivity to amoxicillin [Recommendation Grade D].
1.2.2. suspicion of atypical organisms particularly Mycoplasma pneumoniae [Recommendation Grade D].
2. For a patient who has been classified as pCAP C without previous antibiotic and
2.1. requiring hospitalization, and
2.1.1. has completed the primary immunization against Haemophilus influenzae type b, penicillin G
[100,000 units/kg/day in 4 divided doses] may be given [Recommendation Grade B2].

*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation.

23
2.1.2. has not completed the primary immunization, or immunization status unknown, against
Haemophilus influenzae type b, ampicillin [100 mg/kg/day in 4 divided doses] may be given
[Recommendation Grade B2].
2.2. who can tolerate oral feeding and does not require oxygen support, amoxicillin [40-50 mg/kg/day in
areas of proven low amoxicillin resistance and 90 mk/kg/day maximum dose of 1500 mg/day in 3
divided doses for at most 7 days in areas of proven high amoxicillin resistance] may be given on an
outpatient basis [Recommendation Grade B2].
3. For a patient who has been classified as pCAP D, a specialist may be consulted [Recommendation Grade D].
4. For a patient suspected to have community-acquired methicillin-resistant Staphylococcus aureus,
4.1. vancomycin may be started [Recommendation Grade D].
4.2. a specialist may be consulted [Recommendation Grade D].
5. Ancillary treatment as provided in Clinical Question 11 may be given [Recommendation Grade D].

SUMMARY OF EVIDENCE
1. Decision guides in what empiric treatment should be started for pCAP A, B and C
1.1. Epidemiology of antibiotic-requiring pathogen in the general pediatric population
COUNTRY LAB Streptococcus OTHER BACTERIA ATYPICAL ORGANISM
METHOD AGE +YIELD pneumoniae % [95% AUTHOR
%
STUDY DESIGN % % [95% CI] YEAR
[95% CI]
CI]
Latin America Haemophilus influenzae: 3.64% [1.62–6.42] Mycoplasma pneumoniae
3.56% [0.99–7.64]
and Staphylococcus aureus: 3.44% [2.08–5.11] Chlamydia trachomatis
<5y 30.6% 11.08% Gentile A
Carribean
[7.63 -15.08] 2.97% [0.74–6.60] 2012
Culture, PCR Haemophilus influenzae b:3.08%[1.21–5.79]
Meta-analysis Streptococcus pyogenes: 1.54%[0.49–3.15] Chlamydia pneumoniae
2.60% [0.22–7.46]
Haemophilus influenzae: 38.0%
Klebsiella pneumoniae: 14.3%
Cambodia Pseudomonas aeruginosa:12.3% Vong S
Culture >5y 89.0% 17.7% Not determined 2015
Bordetella pseudomallei: 9.3%
Cross-sectional
Staphylococcus aureus: 3.7%
Mycobacterium sp: 15.7%
China Hemophilus influenzae: 40.8% Mycoplasma pneumoniae Peng Y
Culture Child 50.2% 29.7% 2015
Moraxella catarrhalis: 7.3% 29.82%
Cross-sectional
Finland Hemophilus Influenzae: 38.0%
6m-15y 91% 50% Mycoplasma pneumoniae Honkinen M
Culture Moraxelle catarrhalis: 28.0%
3.0% 2012
Cross-sectional Staphylococcus aureus: 13.0%

1.2. Pattern of antibiotic resistance among antibiotic-requiring pathogens in hospitalized patients


2012-2015 local hospital data reported by Antimicrobial Resistance Surveillance Program showed the
following antimicrobial resistance rates [Antimicrobial Resistance Surveilance Reference Laboratory, Antimicrobial
Resistance Surveilance Program 2012, 2013, 2014, 2015 Annual Reports].
1.21. Streptococcus pneumoniae
2012 2013 2014 2015
Penicillin 8.0% 5.0% 7.0% 7.6%
Chloramphenicol 8.7% 3.0% 4.0% 2.6%
Cotrimoxazole 22.4% 20.0% 17.3% 16.5%
Erythromycin 4.3% 6.0% 4.3 % 5.0%
Azithromycin 0% - - -
Sulbactam-ampicillin 6.7% - - -
Ceftriaxone - 0% - 0%
Levofloxacin - 2.0% - -
1.2.2. Haemophilus influenzae
2012 2013 2014 2015
Chloramphenicol 8.2% 7.0% 13.4% 5.7%
Cotrimoxazole 34.1% 34.0% 42.9% 32.5%
Ampicillin 16.7% 17.0% 12.0% 8.9%
Amox/clavulanic - - 4.1% 5.2%
Sulbactam-ampicilin - 7.0% - 3.4%

24
1.2.3. Staphylococcus aureus
2012 2013 2014 2015
Penicillin 95.4% 95.0% 95.5% 96.0%
Oxacillin 54.9% 53.0% 60.3% 62.6%
Vancomycin 0% 1.0% 0.9% 0.7%
Clindamycin 8.4% 12.0% 11.0% 10.4%
Erythromycin 10.9% 15.0% 12.0% 11.0%
Rifampin - 1.0% 4.1% 4.9%
Ciprofloxacin - 8.0% 7.4% 4.9%
Cotrimoxazole 9.3% 14.0% 22.0% 25.9%
Linezolid 1.6% 2.0% 1.2% 1.7%
1.2.4. Methicillin-resistant Staphylococcus aureus
2012 2013 2014 2015
Rifampin 7.7% 4.0% 6.0% 6.9%
Vancomycin 0% 1.0% 1.0% 0.9%
Clindamycin 13.4% 12.0% 14.% 14.0%
Erythromycin - 15.0% 16.% 14.0%
Ciprofloxacin 7.5% 7.0% 10.% 6.2%
Cotrimoxazole 14.7% 18.0% 26.% 29.0%
Linezolid 3.5% 1.0% 1.7% 2.2%

1.3. Clinical trials with clinical treatment failure, cure rate, relapse rate, adverse event, side effect
readmission, ICU admission and clinical course as clinically important endpoints.
RESULTS
NUMBER CLINICALLY AUTHOR
STUDY DESIGN RISK or ODDS RATIO YEAR
INTERVENTION OF IMPORTANT p VALUE REMARKS
AGE [95% CI]
SUBJECTS ENDPOINT
Risk classification scheme: pCAP A or B
233 vs 133 Cure rate 1.22 [0.50-2.94]
Azithromycin
236 vs 156 Failure rate 0.73 [0.18-2.89]
vs erythromycin
84 vs 69 Side effects 0.92 [0.18-4.73]
124 vs 110 Cure rate 1.61 [0.86-3.08]
Clarithromycin 124 vs 110 Failure rate 0.52 [0.12-2.23]
vs erythromycin 121 vs 105 Relapse rate 0.17 [0.02-1.45]
133 vs 127 Adverse event 1.07 [0.60-1,90]
125 vs 63 Cure rate 1.02 [0.54-1.95]
Azithromycin
vs co-amoxiclav 164 vs 112 Failure rate 1.21 [0.42-2.53]
164 vs 112 Side effect 0.15 [0.04-0.61]
50 vs 50 Cure rate 10.44 [2.85-38.21]
50 vs 50 Side effect 5.21 [0.24-111.24]
Co-amoxiclav 948 vs 839 Failure rate 1.18 [0.91-1.51] Lodha R
Subgroup in vs amoxicillin nonsevere CAP 2013
meta-analysis 203 vs 99 Failure rate 1.71 [0.94-3.11]
<18y severe CAP
Amoxicillin 42 vs 42 Cure rate 2.05 [0.18-23.51]
vs cefuroxime
Amoxicillin 923 vs 142 Failure rate 0.64 [0.41-1]
vs chloramphenicol
Cotrimoxazole 55 vs 56 Cure rate 1.06 [0.47-2.40]
vs chloramphenicol
Amoxicillin 42 vs 40 Cure rate 1.05 [0.06-17.40]
vs clarithomycin
Cefuroxime 42 vs 40 Cure rate 0.51 [0.04-5.89]
vs clarithromycin
Cohort B-lactam monotherapy 1164 Treatment Not Ambroggio
1-18y vs macrolide failure significant L 2015

Amoxicillin 5d vs 10d 40% vs 0%


RCT Greenberg
6-59m 80 mkd Failure rate p=0.16 D 2014
given TID 3d vs 10d 0% vs 0%
Amoxcillin
RCT 3d vs 12.5% vs Florendo S
50 mkd 143 Failure rate
11-59m 5d vs 7d 15.0% vs 0% 2012
BID

25
Risk classification scheme: pCAP C
Amoxicillin 68 vs 86 Failure rate 0.75 [0.17-3.25]
vs procaine penicillin
Cotrimozaxole 349 vs 374 Cure rate 1.58 [0.26-9.69]
vs procaine penicillin 303 vs 311 Failure rate 1.72 [0.41-7.27]
Cotrimozaxole 66 vs 68 Cure rate 1.15 [0.36-3.61]
vs penicillin+ampicillin
Chloramphenicol 559 vs 557 Adverse events 1.26 [0.96-1.66]
vs penicillin+gentamycin 559 vs 557 Readmission < d 30 1.61 [1.02-2.55]
Chloramphenicol+ampicillin 479 vs 47 Failure rate day 5 1.51 [1.04-2.19]
vs gentamycin
Subgroup Lodha R
Chloramphenicol+penicillin 46 vs 51 Cure rate 1.36 [0.47-3.93]
in meta- vs ceftriaxone 2013
analysis
<18y Ampicillin 52 vs 49 Cure rate 0.48 [0.15-15.1]
vs penicillin+chloramphenicol
Benzathine penicillin 135 vs 146 Cure rate 0.43 [0.27-1.01]
vs procaine penicillin
Penicillin+gentamycin 38 vs 33 Failure rate 0.86 [0.05-14.39]
vs co-amoxiclav 55 vs 56 Relapse rate 1.02 [0.24-4.30]
Co-amoxiclav 8/56 vs 7.48 Failure rate 0.98 [0.93-2.92]
vs oxacillin+ceftriaxone
1982 vs 1960 Failure rate day 3 0.95 [0.78-1.15]
Oral vs parenteral antibiotic
for severe pneumonia 1948 vs 1922 Failure rate <5y 0.91 [0.76-1.09]
1048 vs 1028 Relapse rate 1.28 [0.34-4.82]
Cohort Broad vs narrow 236 vs 256 Readmission within 0.25 Queen M
2m-18y spectrum antiobiotic 7 days 2014
Cohort Broad vs narrow 13954 vs ICU admission 0.85 [0.27 -2.73] Wlliams D
<5y spectrum antibiotic 1610 2013
RCT Ampicillin or penicillin 66 vs 253 Treatment failure 7.6% Dinur-Schejter Y
3m-2y vs cefuroxime vs 4.7% 2013
Treatment failure 0.82 [0.55-0.82]
Meta- nd
2 day
analysis Amoxicillin 12364 Das R
3-59 m vs standard IV antibiotic subjects Treatment failure 0.92 [0.76-1.10] 2013
6th day
Meta- Amoxicillin
analysis Lodha R
vs procaine penicillin 68 vs 86 Failure rate 0.75 [0.17-3.25]
<18y 2013
Cohort Penicillin G q 4 vs q6 120 vs 144 Final outcome No diffe- Brandao A
2m-11y ference 2014
RCT Amoxicillin given at home 68 vs 86 Treatment failure HR < 0.01 Patel A
3-59m then hosp vs at hosp alone 1.79 [1.30-2.46] 2015
0.71
Transfer to ICU [Age:1-4y]
> 2nd day 0.14
[Age:5–17y]
0.30
[Age:1-4y]
Mortality
0.58
Cohort Ceftriaxone 4701 vs 8892 [Age:5–17y] Leyenaar J
1-17y vs ceftriaxone+macrolide 0.10 [Age: 2014
All-cause 1-4y]
readmission
<30 days 0.58
[Age:5–17y]
Pneumonia-related 0.96
[Age:1-4y]
readmission <30 days
0.37
[Age:5–17y
Cohort Β-lactam+macrolide 2489 vs Readmission 0.69 (0.41-1.12) Ambroggio L
1-18y vs B-lactam monotherapy 18254 2013
RCT Penicillin G Not Amarilyo G
3m–15y vs IV cefuroxime 58 children Clinical course significant 2014
7.7%
RCT Amoxicillin vs Agwayu A
<2y vs benzyl penicillin Treatment failure 8.0% 2015
[perprotocol
analysis]

26
Clinical Question 7. WHAT TREATMENT SHOULD BE INITIALLY GIVEN IF A VIRAL ETIOLOGY IS
STRONGLY CONSIDERED?

SUBCOMMITTEE MEMBERS
Vivian A. Ancheta
Janet C. Bernardo
Janet Myla Q. Bonleon
Julie Iris C. Clapano
Yadnee V. Estrera

BACKGROUND
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT*
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 [Recommendation Grade A], or clinically suspected
[Recommendation Grade D] cases of influenza.
2. The use of immunomodulators for the treatment of viral pneumonia is not recommended [Recommendation Grade D].
3. Ancillary treatment as provided in Clinical Question 11 may be given [Recommendation Grade D].

2016 KEY RECOMMENDATIONS**


1. For pCAP A, B, C or D in which a non-influenza virus is the suspected pathogen, antiviral drug therapy
may not be beneficial [Recommendation Grade D].
2. For pCAP C or D, antiviral drug therapy for clinically suspected or laboratory-confirmed influenza virus to
reduce
2.1. risk of pneumonia may not be beneficial [Recommendation Grade B1].
2.2. time to symptom resolution may be beneficial [Recommendation Grade B1].
2.2.1. oseltamivir [for infants 3-8 months old at 3 mg/kg per dose twice daily x 5 days, for infants 9-11
months old at 3.5 mg/kg per dose twice daily x 5 days, for >12 months old: body weight <15 kg at
30 mg twice daily x 5 days, >15-23 kg at 45 mg twice daily x 5 days, >23-40 kg at 60 mg twice daily
x 5 days, >40 kg at 75 mg twice daily x 5 days; doses to be started within 48 hours of onset of
influenza-like symptoms.
2.2.2. zanamivir [for children >7 years old at 10 mg (two 5-mg inhalations) twice daily x 5 days,
within 36 hours of onset of influenza-like symptoms.
3. Oseltamivir or zanamivir may be benefical to reduce the burden of pneumonia during a flu epidemic
[Recommendation Grade C1].
4. Symptomatic and ancillary treatment may be beneficial [Recommendation Grade D].
nd
*Grading of recommendation in the 2012 PAPP 2 Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation.

27
SUMMARY OF EVIDENCE
1. Epidemiology
1.1. Local data
1.1.1. Rate of viral pneumonia [ICD code J12.9, J12, J12.0, J12.2, J12.8] relative to all discharges from January
2012 to December 2015 as reported by hospitals accredited by Philippine Pediatric Society : 0.11%.
[ICD 10 Registry, Committee on Registry of Childhood Disease, Philippine Pediatric Society].
1.1.2. Local epidemiology among hosptalized viral CAP
RATE AUTHOR
SITE VIRAL ISOLATE % YEAR
<1y old 1-4y old >5y old
Total 28.1% [106/377]
Cordillera RSV 60.3% 26.4% 0.94% Perez C
Administrative Flu B 1.9% 2.8% 0.94% 2012
Region Flu A 0.94% 2.8% 0
Flu A [H1N1] 1.9% 0 0
Total 61.2% [501/819]
Rhinovirus 30.5% Suzuki A
Tacloban RSV 24.1% 2012
Adenovirus 4.0%
Flu A 2.2%

1.2. Global data


INCIDENCE
AUTHOR
STUDY DESCRIPTION
I2
POOLED %[CI 95%] 2 MIXED % [CI 95%] YEAR
I
Data: worldwide from Apr 2000-Aug 2014
Study design: meta-analysis [21 studies, 10196 subjects]. 57.4 [50.8–64.1] 97.9 29.3 [22.4–36.2] 96.1
PCR based
Europe [12 countries] 61.7 [50.–70.3] 33.8 [18.0–49.5]
AREA Asia [5 countries] 58.0 [47.1–68.8] 23.7 [15.8–31.5]
Other areas [4 countries] 44.2 [34.6–53.8] 29.3 [23.0–35.6]
≤1 y old 76.1 [62.8–89.4] 95.1
AGE 2–5 y old 63.1 [50.2–75.9] 94.1 Wang M
2015
≥6 y old 27.9 [4.3–51.5] 96.3
Rhinovirus 18.9 [14.3–23.4]
RSV 17.5 [13.3–21.6]
Bocavirus 12.7 [8.5–16.9]
VIRAL Parainfluenza 7.8 [6.0–9.5]
ISOLATE Influenza 6.3 [4.7–8.0]
hMetapneumovirus 6.1[ 4.1–8.1]
Adenovirus 6.0 [4.4–7.7]
Coronavirus 3.9 [2.1–5.7]

2. Influenza-like illness.
2.1. Burden of pneumonia during influenza pandemic.
0.59 [0.55-0.62] excess pneumonia visits per 1,000 US population [Self W,2014]
2.2 Clinical trials on neuraminidase inhibitor.
INTERVENTION SUBGROUP ODDS or RISK RATIO MEAN DIFFERENCE AUTHOR
ENDPOINT
STUDY DESIGN ANALYSIS [95% CI] [95% CI] YEAR
3 studies Risk for pneumonia 1.06 [0.62-1.83]
Oseltamivir
1 study Time to first symptom relief -29.40 [-47.04-11.76]
versus placebo
Meta-analysis 2 studies Serious adverse event 1.97 [0.59-6.56 ]
2 studies Vomiting 1.70 [1.23-2.35 ] Jefferson T
Zanamivir 2 studies Risk for pneumonia 0.53 [0.12-2.38] 2014
versus placebo 2 studies Time to first symptom relief -1.08 [-2.32-0.15]
Meta-analysis 2 studies Adverse event: nausea and vomiting 0.54 [0.24-1.22]
2.3. Treatment regimen [American Academy of Pediatrics, Committee on Infectious Diseases, 2015; Kimberlin D,2013]
2.3.1. oseltamivir [for infants 3-8 months old at 3 mg/kg per dose twice daily x 5 days, for infants 9-11 months
old at 3.5 mg/kg per dose twice daily x 5 days, for >12 months old: body weight <15kg at 30 mg twice daily x
5 days, >15-23kg at 45 mg twice daily x 5 days, >23-40kg at 60 mg twice daily x 5 days, >40kg at 75 mg
twice daily x 5 days; doses to be started within 48 hours of onset of influenza-like symptoms.
2.3.2. zanamivir [for children >7 years old at 10mg (two 5-mg inhalations) twice daily x 5 days, within 36
hours of onset of influenza-like symptoms.

3. For ancillary treatment, please see Clinical Question 11.

28
Clinical Question 8. WHEN CAN A PATIENT BE CONSIDERED AS RESPONDING TO CURRENT
THERAPEUTIC MANAGEMENT?

SUBCOMMITTEE MEMBER
Beatriz Praxedez Apolla I. Mandanas

BACKGROUND.
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT*
1. Decrease in respiratory signs and/or defervescense within 72 hours after initiation of antibiotic are predictors of favorable response
[Recommendation Grade D].
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 [Recommendation Grade D].

2016 KEY RECOMMENDATIONS**


1. Good clinical response to current therapeutic management may be assessed based on achieving clinical
stability that is sustained for the immediate past 24 hours [Recommendation Grade D].
1.1. For pCAP A or B, clinical stability may be assessed within 24-48 hours after consultation if
cough has improved or body temperature in Celsius has returned to normal [Recommendation Grade D].
1.2. For pCAP C, clinical stability may be assessed within 24-48 hours after admission [Recommendation
Grade C1] if any of the following physiologic parameters has significantly improved or returned to normal.
1.2.1. Respiratory rate [Recommendation Grade C1] at full minute based on the WHO-defined, age-specific
values for tachypnea [Recommendation Grade D].
1.2.2. Oxygen saturation at room air using pulse oximetry [Recommendation Grade C1].
1.2.3. Body temperature in Celsius [Recommendation Grade C1].
1.2.4. Cardiac rate at full minute based on Pediatric Advanced Life Support age-based values
[Recommendation Grade C2].
1.2.5. Work of breathing [Recommendation Grade D].
1.3. For pCAP D, clinical stability may be assessed within 48-72 hours after admission if all of the
following physiologic parameters have significantly improved: respiratory rate at full minute based on
the WHO-defined, age-specific values for tachypnea, oxygen saturation using pulse oximetry, body
temperature in Celsius, cardiac rate at full minute based on Pediatric Advanced Life Support age-
based values, and work of breathing [Recommendation Grade D].
2. Good clinical response to current therapeutic management may not require chest x-ray or complete blood
count to document treatment success at end of treatment [Recommendation Grade D].

*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation.

29
SUMMARY OF EVIDENCE

1. Clinical stability
For purpose of standardization, the Task Force has defined the following:
1.1. Absolute clinical stability as resolution of ALL pneumonia-associated signs and symptoms AND
recovery of pre-pneumonia health status.
1.2. Approaching clinical stability as resolution of ANY pneumonia-associated sign or symptom OR
delayed recovery of pre-pneumonia health status.
1.3. Time to clinical stability as period in hours from the time an intervention has started up to complete
resolution of any pneumonia-associated sign or symptom.

2. Physiologic endpoints in monitoring for clinical stability

TIME TO RESOLUTION
STUDY DESIGN N STABILITY N AUTHOR
Median (IQR) in hours, CI 95%]
PHYSIOLOGIC ENDPOINT DEFINITION YEAR
AGE
<2y 2-4y 5-17 <2y 2-4y 5-17
Cohort
130 90 101
Single endpoint
1. Fever Temp: 36.0-37.9 101 61 63 14.5 (4.5-45.3) 18.4 (2.8-42.8) 10.6 (0.8-34)
2. Tachycardia 1 21 73 62 4.5 (0.3-18.4) 21.8 (5.7,-1.9) 18 (5.8-42.2)
Normal
3. Tachypnea 97 63 62 38.6 (18.7-68.9) 31.6 (9.5-61.9) 24.3 (10.8-59.2)
4; Needing O2 support None 90 58 61 39.5 (19.2-73.6) 44.2 (24-77.6) 38.3 (18-70.6) Wolf R
334 2015
Multiple endpoints
1. Tachypnea Normal RR 108 72 69 40.5 (20.1-75.0) 39.6 (15.6-79.2) 30.4 (14.7-59.2)
+ needing O2 support None
2. Tachypnea + tachycardia Normal RR,HR 109 73 68 40.2 (19.5-73.9) 35.9 (15.9-77.6) 29.8 (17.2-56.6)
+ needing O2 support None
3. Tachypnea + fever Normal RR, none 110 77 73 40.5 (20.7-70.1) 39.1 (18.4-77.6) 28.2 (14.7-44.7)
+ needing O2 support None
4.Tachypnea + tachycardia Normal RR,HR 110 72 71 40.5 (20.7-70.1) 39.7 (20.1-77.5) 29.2 (18.2-54)
+ fever + needing O2 support None
1
Based on American Heart Association. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and
emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support. Pediatrics 2006; 117:e989–1004.

TIME TO NUMBER OF SUBJECTS WITH AUTHOR


RESOLUTION PERSISTENT ABNORMALITY YEAR
STUDY DESIGN STABILITY N Median BEYOND 48 HOURS
PHYSIOLOGIC ENDPOINT N DEFINITION [50th percentile] DAY OF OPD VISIT
In hours DISCHARGE AT DAY 14
AGE
Cohort <1y >1y <1y >1y <1y >1y <1y >1y Izadnegahdar R
Single endpoint 2012
1. Tachypnea 2174 1
1703 1011 22 48 135 381 11 70
Normal
2. Fever Normal 629 12 15 0
3. O2 sat <92% Normal 192 10 31 0
1
Based on data from Fleming S: Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a
systematic review of observational studies. Lancet 2011; 377:1011–1018.

30
Clinical Question 9. WHAT SHOULD BE DONE IF A PATIENT IS NOT RESPONDING TO CURRENT
THERAPEUTIC INTERVENTION?

COMMITTEE MEMBERS
Catherine S. Palaypayon
Raymund Anthony L. Manuel

BACKGROUND
nd
2012 2 PAPP UPDATE SUMMARY HIGHLIGHT*
1. If a patient classified as either pCAP A or pCAP B is not responding to the current antibiotic within 72 hours, consider any of the
following [Recommendation Grade D]:
1.1. Other diagnosis
1.1.1. Coexisting illness
1.1.2. Conditions simulating pneumonia
1.2. Other etiologic agents for which CRP, chest x-ray or CBC may be used to determine the nature of the pathogen
1.2.1. May add an oral macrolide if atypical organism is highly considered
1.2.2. May change to another antibiotic if microbial resistance is highly considered
2. If an in-patient classified as pCAP C is not responding to the current antibiotic within 72 hours, consider any of the ff [Recommendation Grade D].
2.1. Other diagnosis
2.1.1. Coexisting illness.
2.1.2. Conditions simulating pneumonia
2.2. Consider other etiologic agents for which CRP, chest x-ray or CBC may be used to determine the nature of the pathogen
2.2.1. May add an oral macrolide if atypical organism is highly considered
2.2.2. May change to another antibiotic if microbial resistance is highly considered
2.3. May refer to a specialist
3. If an in-patient classified as pCAP D is not responding to the current antibiotic within 72 hours, immediate consultation with a
specialist should be done [Recommendation Grade D]

2016 KEY RECOMMENDATIONS**


1. If a patient classified as either pCAP A or pCAP B is not improving, or clinically worsening, within 72 hours
after initiating a therapeutic intervention [treatment failure], diagnostic evaluation to determine if any of
the following is present may be considered [Recommendation Grade D].
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
1.3.1.1. Necrotizing pneumonia
1.3.1.2. Pleural effusion
1.3.2. Asthma
1.3.3. Pulmonary tuberculosis
2. If a patient below 5 years of age [Recommendation Grade B1], and 5 years old or more [Recommendation Grade D]
classified as pCAP C is not improving, or clinically worsening, within 48 hours after initiating a therapeutic
intervention [treatment failure], diagnostic evaluation to determine if any of the following is present may be
considered.
2.1. Coexisting or other etiologic agents [Recommendation Grade C1]
2.2. Etiologic agent resistant to current antibiotic, if being given [Recommendation Grade D]
2.3. Other diagnosis
2.3.1. Pneumonia-related complication [Recommendation Grade B2]
2.3.1.1. Acute respiratory failure
2.3.1.2. Pleural effusion
2.3.1.3. Pneumothorax
2.3.1.4. Necrotizing pneumonia
2.3.1.5. Lung abscess
2.3.2. Asthma [Recommendation Grade D].
2.3.3. Pulmonary tuberculosis [Recommendation Grade D]
2.3.4. Sepsis [Recommendation Grade C2]
3. If a patient classified as pCAP D is clinically worsening within 24 hours after initiating a therapeutic
intervention, referral to a specialist may be done [Recommendation Grade D].

*CQ 9 has been changed in the current guideline. Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and
Management of Pediatric Community-acquired Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation.

31
SUMMARY OF EVIDENCE
1. Description of failure of standard treatment at 48 hours after admission
COUNTRY n/N
DESCRIPTION OF TREATMENT FAILURE AUTHOR
STUDY DESIGN RATE
AGE GROUP [95% CI] YEAR
pCAP C [or SEVERE PNEUMONIA]
1. Development of signs of very severe pneumonia at any time, or 3/169
2. Absence of improvement of ALL of the following: indrawing (persistence), measured temperature 1.8% Agweyu A
reduction of ≥0.5 °C and respiratory rate (reduction of ≥5 bpm), or [0.4–5.1] 2014
Kenya 3. Identification of pathogen with in vitro resistance to antibiotics at any time point
Cohort 1. Worsening, compared to admission findings, of one or more of these clinical abnomalities: conscious
2-59m level, SaO2 <90%; RR (must have increased by at least 5 breaths/min), or temp (if initially<37.5°C, 42/453 Webb C
12% 2012
must have increased to >37.5°C); or
2. No improvement in any these clinical abnormalities; or
3. New findings of empyema, bacterial meningitis, shock or renal impairment (creatinine >100 mmol/L)
Nepal Failure to improve1 AND 1. a requirement for a change in antibiotics to second line therapy; or 209/610 Basnet S
Cohort 2. development of empyema or pneumothorax requiring surgical intervention; or 35% 2015
2-35m 3. admission to the intensive care unit for ventilator and/or inotropic support.
pCAP D [or VERY SEVERE PNEUMONIA]
1. Observed deteriorating level of consciousness or development of respiratory failure resulting in the
need for ICU transfer at any time point; or
2. Chest X-ray findings of lung abscess, bullae formation or PTB at any time point; or 43/201 Agweyu A
3. Absence of improvement of ALL of the following: indrawing (persistence), measured temperature re- 21.4% 2014
duction of ≥0.5°C, RR (reduction of ≥5 bpm), ability to drink AND requirement of supplementary O2; or [15.9–27]
Kenya 4. Identification of a pathogen on blood culture or from pleural fluid with in vitro resistance to antibiotics
Cohort at any time point.
2-59m 1. Worsening, compared to admission findings, of one or more of these clinical abnormalities: conscious
level, SaO <90%; respiratory rate (must have increased by at least 5 breaths/min), or temp (if
2
initially <37.5°C, must have increased to >37.5°C); or 69/165 Webb C
2. No improvement in any these clinical abnormalities; or 32% 2012
3. New findings of empyema, bacterial meningitis, signs of shock or renal impairment
(creatinine >100 mmol/L)
pCAP C [or SEVERE PNEUMONIA] and pCAP D [or VERY SEVERE PNEUMONIA]
1. No improvement or worsening of tachypnea or lower chest indrawing; or
India 2. New appearance, no improvement or worsening of danger signs such as inability to drink, abnormal 37/181 Jain D
Case control sleepiness, difficult to awake from sleep, stridor in a calm child, central cyanosis, and convulsions; or 20.4% 2013
3-59m 3. Occurrence of empyema, pneumothorax, lung abscess, meningitis, septicaemia, shock, respiratory
failure)
1
Persistence of lower chest indrawing or of any danger signs initially present despite 48 hours of treatment or appearance of new danger signs or
hypoxia with deterioration of a patient’s clinical status any time after initiation of treatment

2. Conditions associated with treatment failure for severe and nonsevere pneumonia
CONDITIONS ASSOCIATED WITH TREATMENT FAILURE AUTHOR
n/N [RATE]
AT LEAST 48 HOURS AFTER ADMISSION YEAR
Clinician’s decision to change treatment in absence of criteria 54/100 (54.0%)
Persistence of tachypnea, fever and indrawing 25/100 (25.0%)
Documented signs of deteriorating clinical status 12/100 (12.0%) Agweyu A
2014
Radiological findings informing change of treatment 2/100 (2.0%)
Bacteriological findings informing change of treatment 1/100 (1.0%)
Persistence of tachypnea or lower chest indrawing 10/31 (32.2%)
Empyema / pneumothorax 6/31 (19.3%)
Hypoxemia [SaO2 <90%] 7/31 (22.5%) Jain D
Persistence or new appearance of danger signs 5/31 (16.1%) 2013
Meningitis 2/31 (6.4%)
Lung abscess 1/31 (3.2%)
48 hr after admission 5 days after admission
Worsening conscious level 4 ( 3.6%) 3 ( 5.0%)
Worsening SaO2 19 (17.0%) 2 ( 3.0%)
Persistent SaO2 <90% 0 19 (31.0%)
Worsening respiratory rate 61 (55.0%) 12 (19.0%)
Webb C
Worsening temperature 22 (20.0%) 1 ( 2.0%)
2012
Persistent lower chest wall indrawing 0 31 (50.0%)
New bacterial meningitis 2 ( 1.8%) 2 ( 3.0%)
New renal impairment 0 1 ( 2.0%)
New signs of shock 3 ( 2.7%) 4 ( 6.0%)
New empyema 0 0
Admission to the intensive care unit 7/209 (3.34%)
OR [95% CI] 1
p VALUE Basnet S
Nasopharyngeal aspirate positive for human metapneumovirus 2.34 (0.62- 8.81) 0.209 2015
Nasopharyngeal aspirate positive for RSV 1.47 (0.91, 2.38) 0.115
1
Odds to having treatment failure

32
Clinical Question 10. WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA BE STARTED?

COMMITTEE MEMBERS
Jean Marie E. Jamero
Beverly D. de la Cruz

BACKGROUND
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT *
1. For pCAP C,
1.1. 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 [Recommendation Grade D]:
1.1.1. Responsive to current antibiotic therapy as defined in Clinical Question 8
1.1.2. Tolerance to feeding, and without vomiting or diarrhea
1.1.3. Without any current pulmonary (effusion / empyema; abscess; air leak, lobar consolidation, necrotizing pneumonia)
or extrapulmonary complications; and
1.1.4. Without oxygen support
1.2. switch therapy from three [3] days of parenteral ampicillin to
1.2.1. amoxicillin [40-50 mg/kg/day for 4 days] [Recommendation Grade B].
2. For pCAP D, referal to a specialist should be considered [Recommendation Grade D].

2016 KEY RECOMMENDATIONS**


1. For pCAP C, switch from intravenous antibiotic administration to oral form may be beneficial to reduce length
of hospital stay [Recommendation Grade C1] provided all of the following are present [Recommendation Grade D].
1.1. Current parenteral antibiotic has been given for at least 24 hours
1.2. At least afebrile within the last 8 hours without current antipyretic drug
1.3. Responsive to current antibiotic therapy as defined in Clinical Question 8
1.4. Able to feed, and without vomiting or diarrhea
1.5. Without any current pulmonary [effusion / empyema, abscess, air leak, lobar consolidation or
necrotizing pneumonia] or extrapulmonary [meningitis or sepsis] complications
1.6. Oxygen saturation > 95% at room air
2. For pCAP D, referral to a specialist may be done if switch therapy is considered.

*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation.

SUMMARY OF EVIDENCE.
RESULTS
CAP SEVERITY
p AUTHOR
STUDY DESIGN Control group Switch therapy group
CLINICALLY IMPORTANT ENDPOINT VALUE YEAR
AGE GROUP
n=31 n=26

Mortality 0 0 -
Severe CAP RCT, Complications 0 0 - In-iw S
non-inferiority 2015
1-60m Readmission within 30 days 6.5% 3.8% 0.66
Length of stay 4.77+1.5 days 3.8+1.6 days 0.019

33
Clinical Question 11. WHAT ANCILLARY TREATMENT CAN BE GIVEN?

COMMITTEE MEMBER
Grace V. Malayan

BACKGROUND
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT*
1. For pCAP A or pCAP B,
1.1. cough preparation [Recommendation Grade A], elemental zinc [Recommendation Grade B], vitamin A [Recommendation Grade D],
vitamin D [Recommendation Grade D], probiotic [Recommendation Grade D] and chest physiotherapy [Recommendation
Grade D] should not be routinely given during the course of illness.
1.2. a bronchodilator may be administered in the presence of wheezing [Recommendation Grade D].
2. For pCAP C,
2.1. oxygen and hydration should be administered whenever applicable [Recommendation Grade D].
2.1.1. Oxygen delivery through nasal catheter is as effective as using nasal prong [Recommendation Grade A].
2.2. a bronchodilator may be administered only in the presence of wheezing [Recommendation Grade D].
2.2.2. Steroid may be added to a bronchodilator [Recommendation Grade B].
2.3. a probiotic may be administered [Recommendation Grade B].
2.4. cough preparation, elemental zinc, vitamin A, vitamin D and chest physiotherapy should not be routinely given during the
course of illness [Recommendation Grade A].
3. For pCAP D, referral to a specialist should be considered [Recommendation Grade D].

2016 KEY RECOMMENDATIONS**


1. During the course of illness for pCAP A or pCAP B, the following
1.1. may be beneficial.
1.1.1. Oral steroid in a patient with coexisting asthma [Recommendation Grade D].
1.1.2. Bronchodilator in the presence of wheezing [Recommendation Grade D].
1.2. may not be beneficial.
1.2.1. Cough preparation [Recommendation Grade A1] or parenteral steroid in a patient without asthma
[Recommendation Grade B1].
1.2.2. Elemental zinc, vitamin D 3 and probiotic [Recommendation Grade D].
2. During the course of illness for pCAP C, the following
2.1. may be beneficial.
2.1.1. Use of either nasal catheter or nasal prong in administering oxygen [Recommendation Grade A1].
2.1.2. Zinc supplement in reducing mortality [Recommendation Grade B1].
2.1.3. Use of bubble CPAP instead of low flow oxygen in improving oxygenation [Recommendation Grade C2].
2.1.4. Steroid or spirulina in reducing length of stay [Recommendation Grade B2].
2.1.5. Oxygen for oxygen saturation below 95% at room air in improving oxygenation [Recommendation Grade D].
2.2. may not be beneficial.
2.2.1. Zinc supplement in reducing treatment failure or length of hospital stay [Recommendation Grade A1].
2.2.2. Vitamin D 3 in reducing length of hospital stay [Recommendation Grade A1].
2.2.3. Parenteral steroid, probiotic, virgin coconut oil, oral folate and nebulization using saline or
acetylcysteine [Recommendation Grade C2].
3. During the course of illness for pCAP D, referral to a specialist may be beneficial [Recommendation Grade D].

*Grading of recommendation in the 2012 PAPP 2nd Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation

34
SUMMARY OF EVIDENCE

1. Interventions that may be beneficial as an ancillary treatment


RESULTS
INTERVENTION CLINICALLY AUTHOR
RISK or ODDS p
STUDY DESIGN IMPORTANT ENDPOINT REMARKS YEAR
RATIO [95% CI] VALUE
Intervention of proven benefit in pCAP C to reduce mortality.
Zinc Srinivasan M
Case fatality 0.33 [0.15-0.76]
RCT, double-blind, placebo-controlled 2012

Interventions of equal benefit in pCAP C to reduce treatment failure.


O2 delivery: bubble CPAP vs low flow O 2 Treatment failure 0.27 [0.77-0.99] 0.0026 Trial stopped Chisti M
RCT earlier 2015
Interventions of equal benefit in pCAP C to achieve adequate oxygen saturation.
O2 delivery:nasal prong vs nasopharyngeal catheter Failure to achieve Reyes-Rojas M
Meta-analysis adequate SaO2 0.93 [0.36 -2.38] 2014

Interventions of potential benefit in pCAP C to reduce length of hospital stay and improve crackles score.
Steroid 0.019 Justina M
RCT, double-blind, placebo-controlled 2012
Length of stay
Spirulina 0.0006 Dioniso-Delfin T
RCT, open label 2012
Zinc Crackles score 0.034 Guinto, M
RCT 2014

2. Interventions requiring more studies to assess benefit as an ancillary treatment

Interventions in pCAP A or B.
Cough preparation Not improved 0.80 [0.38-1.67] Combined child Chang CC
Meta-analysis and adult 2014
Steroid 2.38 [1.03-5.52] 0.04 [-] asthma hx Ambroggio L
Retrospective cohort Treatment failure 2014
1.12 [0.43-2.92] 0.80 [+] asthma hx
Interventions in pCAP C.
Steroid Risk of readmission Justina M
RCT, double-blind, placebo-controlled 0.46 2012
Chest physiotherapy Chaves G
Meta-analysis 0.11-0.79 2013
Vitamin D Das R
Meta-analysis 0.29
Length of stay 2013
Pooled mean Bernabe J
Zinc diff: -5.75 2012
Meta-analysis [-11.54-0.04]
0.88 Macalino M
[0.71-1.10] 2013
1.3 Wadha N
[0.8-2.1] 2013
Treatment failure Sempe rtegu F
1.00 2012
[0.68-1.50]
Shah G
0.423 2012
Zinc
Time to normalization of RR, 0.306 Srinivasan M
RCT, double-blind, placebo-controlled temperature 0.897 2012
and SaO2 0.823
0.05 Rulloda M
2012
Length of stay 0.193 Shah GS
2012
0.089 Low Fataki M
enrollment 2014
O2 delivery:bubble CPAP vs high flow O2 Treatment failure 0.50 Trial stopped Chisti M
RCT, open label [0.11-2.99] earlier 2015
Virgin coconut oil 0.336 Vierneza M
RCT 2012
Probiotic Mean: Becina P
RCT 3.2d vs 3.3d 2014
Oral folate Mean: Villanueva J
RCT, placebo-controlled Length of stay 4.0d vs 4.8d 2013
Vitamin D3 Not Mondragon A
RCT significant 2014
Nebulization: acetylcysteine vs saline Mean: Martinez M
RCT 2.5d vs 2.9d 2012
Nebulization: saline or bronchodilator Not Delizo M
Cross-sectional significant 2014

35
Clinical Question 12. HOW CAN PNEUMONIA BE PREVENTED?

COMMITTEE MEMBERS
Amelia G. Cunanan
Ma. Lucia P. Yanga

BACKGROUND.
2012 2nd PAPP UPDATE SUMMARY HIGHLIGHT*
1. The following should be given to prevent pneumonia.
1.1. Vaccine against 1.1.1. Streptococcus pneumoniae (conjugate type) [Recommendation Grade A]
1.1.2. Influenza [Recommendation Grade A]
1.1.3. Diphtheria, Pertussis, Rubeola, Varicella, Haemophilus Influenzae type b [Recommendation Grade A]
1.2 Micronutrient. 1.2.1. Elemental zinc for ages 2 to 59 months to be given for 4 to 6 months [Recommendation Grade A]
2. The following may be given to prevent pneumonia.
2.1 Micronutrient 2.1.1. Vitamin D3 supplementation [Recommendation Grade B]
3. The following should not be given to prevent pneumonia:
3.1 Micronutrient 3.1.1. Vitamin A [Recommendation Grade A]

2016 KEY RECOMMENDATIONS**


1. The following are beneficial in reducing the burden of hospitalization because of pneumonia.
1.1. Conjugated vaccine [PCV 10 or 13] against Streptococcus pneumoniae [Recommendation Grade A1]
1.2. Vaccine against Haemophilus Influenzae type b [Recommendation Grade C1], Influenza sp
[Recommendation Grade C2 ] and Diphtheria, Pertussis, Rubeola and Varicella [Recommendation Grade D]
1.3. Breastfeeding [Recommendation Grade B1]
1.4. Avoidance of cigarette smoke [Recommendation Grade B1] and biomass fuel [Recommendation Grade C1]
2. The following are not beneficial in reducing the clinical impact of pneumonia.
2.1. Zinc supplement [Recommendation Grade A1]
2.2. Vitamin D [Recommendation Grade A2]
nd
*Grading of recommendation in the 2012 PAPP 2 Update in the Evaluation and Management of Pediatric Community-acquired
Pneumonia was based on Sacket DL, Straus SE: Evidence Based Medicine 2000.
**Please see Methodology for description of grading of recommendation

SUMMARY OF EVIDENCE
1. Rationale for prevention: burden of illness
BURDEN SITE STUDY AGE AVERAGE NUMBER MEAN RATE SOURCE
PERIOD GROUP PER YEAR
MORBIDITY
Acute lower respiratory <5y 286 073 Department
2012-14 of Health
1

infection and pneumonia 5-14y 326,326


Hosp for pneumonia Nationwide Philippine
ICD code 10 18.0,18.9, 18.91, 2012-15 28d-19y 242,086 7.9% 2 Pediatric
18.92,18.93 Society,Inc3

MORTALITY
Pneumonia-related. Philippine
Nationwide 4 Pediatric
ICD code 10 J18.0,18.9, 18.91, 2.26% Society,Inc3
18.92,18.93
Pneumonia-related Worldwide 2000-13 <5y 0.935 [UR5 0.817-1.057] 14.9% [UR5 13.0-16.8] Liu L,2014
6
ECONOMIC BURDEN
AGE 7
PNEUMONIA SEVERITY STUDY PERIOD GROUP ESTIMATED TOTAL HEALTH CARE COST

Moderate risk PhP 8.48 billion Mendoza B


2012 Adult 2015
High risk PhP 643.76 million
1
2012, 2013, and 2014 Annual Reports Field Health Services Information System Department of Health.
2
Rate = discharges due to pneumonia / total number of discharges from Jan 1, 2012 to December 31, 2015.
3
ICD 10 Registry, Committee on Registry of Childhood Disease, Philippine Pediatric Society, Inc.
4
Rate = deaths due to pneumonia / total number of discharges due to pneumonia from Jan 1, 2012 to December 31, 2015.
5
UR – uncertainty range
6
Gap in knowledge: no available data exclusive for children.
7
Estimated mean value based on Philippine Health Insurance claims and estimated healthcare cost.

36
2. Interventions that may be beneficial to prevent pneumonia, or reduce pneumonia-related morbidity
and mortality
CLINICALLY RESULTS
INTERVENTION COUNTRY AUTHOR
IMPORTANT RISK, HAZARD or ODDS
STUDY DESIGN AGE REMARKS YEAR
ENDPOINT RATIO [95% CI]
Intervention of proven benefit: vaccination
CAP 43.2% vs 39.2%, p=0.005 Moore M
2015
USA
<18y All-cause CAP hosp 17-21% reduction in <5y Simonsen L
Empyema 37-50% reduction in <18y 2014
PCV 13 Uruguay CAP All-cause 78.1% reduction Pirez M
Time-trend analysis 2013
<14y hosp Pneumoccous 92.4% reduction
Argentina Radiologic CAP 20.1 [13.1-26.4], p<0.001 Gentile A
<5y 2015
hospitalization
Alaska Pneumococcal CAP 57% reduction Bruce M
<5y hospitalization 2015

PCV 13 USA Griffin M


All-cause CAP 27% reduction 2014
Cohort <2y
hospitalization
PCV 7-13 England CAP hospitalization No difference Saxena S
Time-trend analysis <2y 2015
Empyema 0.58 [0.34-0.99]
PCV 7-13 Israel Annual incidence of 68% decline in OPD visits Greenberg D
Time-trend analysis <5y alveolar pneumonia 32% decine in hospitalization 2015

PCV 7-13 Italy Pneumococcal CAP 0.43 Martinelli D


Cohort <5y hospitalization [0.21-0-90] 2013
PCV 10 Brazil All-cause CAP 23-28% reduction Afonso E
2013
Time-series analysis <2y hospitalization
PCV 10 Brazil CAP prevalence 40% reduction Abrao MA
Cross-sectional <2y 2015

South Consolidation CAP Vaccine efficacy:


PCV 10 23.4% [8.8-35.7] Tregnaghi M
America 2014
RCT,double-blind Children Adverse events 21.5%(20.7-22.2) vs
22.6% (21.9-23.4)
Hib vaccine Vietnam Radiologic CAP 39% reduction Flasche S
2014
Time-series analysis <5y

Interventions of potential benefit


Risk for CAP: Kenya Nonsevere CAP 4.2 [3.9-4.6] Ekaru H
Firewood,charcoal use Children Severe CAP 1.1 [1.02-1.26] 2012
Cross-sectional
New Zealand Grant V
CAP 1.99 [1.05-3.81] 2012
Risk for CAP: smoker <5y
Case control Tomas A
Philippines Severe CAP 2012-2015
<2y 2.60 [1.57-4.30]
Protective against CAP:
1.breastfeeding >3m Brazil Association with
2.no smokers Barsam F
6m-13y hospitalization [-] association
Case control 2013
for CAP
Protective against Kenya First physician HIV exposed but Ásbjornsdottir K
CAP: breastfeeding Infants diagnosed pneumonia 0.53 [0.39-0.73)
uninfected 2014
Cohort

3. Interventions requiring more studies to assess benefit in reducing the clinical impact of pneumonia
Vit D Acute lower respiratory [+] association between
Meta-analysis Children Vit D deficiency and Larkin A
infection [ALRI] severity 2014
[13 studies] increasing severity of ALRI
Zinc Fu W
Preschool Pneumonia-related 0.52 [0.11-2.39] 2013
Meta-analysis
[3 studies] children mortality

37
BIBLIOGRAPHY
Clinical Question 1. Who shall be considered as having community acquired pneumonia?
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in a US-based pediatric emergency department. Pediatr Infect Dis J 2012;31:561-4.
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Research 2013,http://www.hoajonline.com/journals/pdf/2053-6739-1-1.
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to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study. BMJ 2013;346:f1706
doi:10.1136/bmj.f1706;1-16.
6 Alagadan S, Lagunilla K,: Analysis of single and multiple clinical variables associated with the radiologic diagnosis of community-acquired
pneumonia among children 1 month to 16 years old in a private tertiary hospital: a 3 year retrospective case-control study. Philippine
Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
7 Arquiza T, Cabanilla C.: Development and validation of a clinical scoring tool to predict radiographic pneumonia among children 3 months
to 5 years in a pediatric emergency department 2013. Philippine Academy of Pediatric Pulmonologists, Inc. Unpublished.
8 Pereda M, Chavez M, Hooper-Miele C, Gilman R, Steinhoff M, Ellington L, Gross M, Price C, Tielsch J, Checkley W.: Lung Ultrasound for
the Diagnosis of Pneumonia in Children: A Meta-analysis. Pediatrics 2015;135:714-722.
9 Domingo E, Cabanilla C.: Scoring system to predict community-acquired pneumonia based on clinical indicators among children 3 months
- 5 years old seen at the outpatient department of the Philippine Children’s Medical Center. Philippine Pediatric Society, Inc. Abstracts
Philippine Pediatric Researches 2012-2015.
10 Chisti M, Salam M, Ashraf H, Faruque A, Bardhan P, Das S, Shahunja K, Shahid A, Tahmeed A.: Clinical Signs of Radiologic Pneumonia
in Under-Five Hypokalemic Diarrheal Children Admitted to an Urban Hospital in Bangladesh. PLoS ONE 2013 8:e71911.doi:10.1371/
journal.pone.0071911.

Clinical Question 2. Who will require admission?


1 Ramachandran P, Nedunchelian K, Vengatesan A, Suresh S.: Risk Factors for Mortality in Community–Acquired Pneumonia Among
Children Aged 1-59 Months Admitted in a Referral Hospital. Indian Pediatrics 2012;49:889-895.
2 Agweyu A, Kibore M, Digolo L, Kosgei C, Maina V, Mugane S, Muma S, Wachira J, Waiyego M, Maleche-Obimbo E.: Prevalence and
correlates of treatment failure among Kenyan children hospitalised with severe community-acquired pneumonia: a prospective study of the
clinical effectiveness of WHO pneumonia case management guidelines. Tropical Medicine and International Health 2014;19:1310-1320.
3 Webb C, Ngama M, Ngatia A, Shebbe M, Morpeth S, Mwarumba S, Bett A, Nokes J, Seale A, Kazungu S, Munywoki P, Hammitt L,
Scott A, Berkley J.: Treatment Failure among Kenyan Children with Severe Pneumonia – a Cohort Study. Pediatr Infect Dis J 2012;
31:e152–e157.doi:10.1097/INF.0b013e3182638012.
4 Ferreira S, Sant'anna C, March M de F, Santos M, Cunha AJ.: Lethality by pneumonia and factors associated to death. J Pediatr (Rio J);
2014;90:92-7.
5 Patel A, Bang A, Singh M, Dhande L, Chelliah L, Malik A, Khadse S; ISPOT Study Group.: A randomized controlled trial of hospital
versus home based therapy with oral amoxicillin for severe pneumonia in children aged 3-59 months: The India CLEN Severe
Pneumonia Oral Therapy (ISPOT) Study. BMC Pediatr 2015;15:186.doi:10.1186/s12887-015-0510-9.

Clinical Question 3. What diagnostic aids are initially requested for ambulatory patients?
No articles are available for review.

Clinical Question 4. What diagnostic aids are initially requested for inpatients?
1 Elemraid M, Rushton S, Thomas M, Spencer D, Gennery A, Clark J.: Utility of inflammatory markers in predicting the aetiology of
pneumonia in children. Diagn Microbiol Infect Dis 2014;79:458-62.
2 Galetto-Lacour A, Alcoba G, Posfay-Barbe K, Cevey-Macherel M, Gehri M, Ochs M, Brookes R, Siegrist C, Gervaix A.: Elevated
inflammatory markers combined with positive pneumococcal urinary antigen are a good predictor of pneumococcal community-
acquired pneumonia in children. Pediatr Infect Dis J 2013;32:1175-9.
3 Hoshina T, Nanishi E, Kanno S, Nishio H, Kusuhara K, Hara T.: The utility of biomarkers in differentiating bacterial from non-bacterial lower
respiratory tract infection in hospitalized children: difference of the diagnostic performance between acute pneumonia and bronchitis.
J Infect Chemother 2014;20:616-20.
4 Huang H, Ideh R, Gitau E, Thézénas M, Jallow M, Ebruke B, Chimah O, Oluwalana C, Karanja H, Mackenzie G, Adegbola R, Kwiatkowski D,
Kessler B, Berkley J, Howie S, Casals-Pascual C.: Discovery and validation of biomarkers to guide clinical management of pneumonia in
African children. Clin Infect Dis 2014;58:1707-15.
5 Gao J, Yue B, Li H, Chen R, Wu C, Xiao M.: Epidemiology and clinical features of segmental/lobar pattern Mycoplasma pneumoniae
pneumonia: A ten-year retrospective clinical study. Exp Ther Med 2015;10:2337-2344.
6 Nascimento-Carvalho C, Araújo-Neto C, Ruuskanen O.: Association between bacterial infection and radiologically confirmed pneumonia
among children. Pediatr Infect Dis J 2015;34:490-3.
7 Medjo B, Atanaskovic-Markovic M, Radic S, Nikolic D, Lukac M, Djukic S.: Mycoplasma pneumoniae as a causative agent of community-
acquired pneumonia in children.: clinical features and laboratory diagnosis. Ital J Pediatr 2014;18;104:1-7
8 Bekdas M, Goksugur S, Sarac E, Erkocoglu M, Demircioglu F.: Neutrophil/lymphocyte and C-reactive protein/mean platelet volume ratios
in differentiating between viral and bacterial pneumonias and diagnosing early complications in children. Saudi Med J 2014;35:442-7.
9 Krenke K, Sanocki M, Urbankowska E, Kraj G, Krawiec M, Urbankowski T, Peradzyńska J, Kulus M.: Necrotizing Pneumonia and Its
Complications in Children Adv Exp Med Biol. 2015;857:9-17.doi:10.1007/5584_2014_99.
10 Lai S, Wong K, Liao S.: Value of Lung Ultrasonography in the Diagnosis and Outcome Prediction of Pediatric Community-Acquired
Pneumonia with Necrotizing Change. PLoS One 2015;10:e0130082. doi: 10.1371/journal.pone.0130082.eCollection 2015.

38
11 Honkinen M, Lahti E, Österback R, Ruuskanen O, Waris M.: Viruses and bacteria in sputum samples of children with community-acquired
pneumonia. Clin Microbiol Infect 2012;18:300-7. doi:10.1111/j.1469-0691.2011.03603.
12 Vong S, Guillard B, Borand L, Rammaert B, Goyet S, Te V, Try P, Hem S, Rith S, Ly S, Cavailler C, Mayaud C, Buchy P.: Acute lower
respiratory infections in ≥5 year -old hospitalized patients in Cambodia, a low-income tropical country: clinical characteristics and
pathogenic etiology. BMC Infectious Diseases 2013;13:97.
13 Gotoh K, Nishimura N, Ohshima Y, Arakawa Y, Hosono H, Yamamoto Y, Iwata Y, Nakane K, Funahashi K, Ozaki T.: Detection of
Mycoplasma pneumoniae by loop-mediated isothermal amplification (LAMP) assay and serology in pediatric community-acquired
pneumonia. J Infect Chemother 2012;18:662-7.doi: 10.1007/s10156-012-0388-5.
14 Chen Y, Liu P, Huang Y, Chen C, Chiu L, Huang N, Hsieh K, Chen Y.: Comparison of diagnostic tools with multiplex polymerase chain
reaction for pediatric lower respiratory tract infection: a single center study. J Microbiol Immunol Infect 2013;46:413-8.
doi:10.1016/j.jmii.2012.07.016.
15 Howie S, Morris G, Tokarz R, Ebruke B, Machuka E, Ideh R, Chimah O, Secka O, Townend J, Dione M, Oluwalana C, Njie M, Jallow M,
Hill P, Antonio M, Greenwood B, Briese T, Mulholland K, Corrah T, Lipkin W, Adegbola R.: Etiology of severe childhood pneumonia in
the Gambia, West Africa, determined by conventional and molecular microbiological analyses of lung and pleural aspirate samples. Clin
Infect Dis 2014;59:682-5.doi:10.1093/cid/ciu384.
16 Deceuninck G, Quach C, Panagopoulos M, Thibeault R, Côté-BoileauT, Tapiéro B, Coïc L, De Wals P, Ovetchkine P.: Pediatric Pleural
Empyema in the Province of Quebec: Analysis of a 10-Fold Increase Between 1990 and 2007. J Pediatric Infect Dis Soc 2014;3:119-26.
doi:10.1093/jpids/pit075.
17 Heine D, Cochran C, Moore M, Titus M, Andrews A.: The prevalence of bacteremia in pediatric patients with community-acquired
pneumonia: guidelines to reduce the frequency of obtaining blood cultures. Hosp Pediatr 2013;3:92-6.
18 Iroh Tam P, Bernstein E, Ma X, Ferrieri P.: Blood Culture in Evaluation of Pediatric Community-Acquired Pneumonia: A Systematic
Review and Meta-analysis. Hosp Pediatr 2015;5:324-36.doi:10.1542/hpeds.2014-0138.
19 Chisti M, Graham S, Duke T, Ahmed T, Ashraf H, Faruque A, Vincente S, Banu S, Raqib R, Salam M.: A Prospective Study of the
Prevalence of Tuberculosis and Bacteraemia in Bangladeshi Children with Severe Malnutrition and Pneumonia Including an Evaluation
of Xpert MTB/RIF Assay. PLoS ONE 2014;9: e93776. doi:10.1371/journal.pone.0093776.
20 Lai E, Nathan A, de Bruyne J, Chan L.: Should all children admitted with community acquired pneumonia have blood cultures taken?
Indian J Pediatr 2015;82:439-44
21 Parikh K, Davis A, Pavuluri P.: Do we need this blood culture? Hosp Pediatr 2014;4:78-84 doi:10.1542/hpeds.2013-0053.
22 Myers A, Hall M, Williams D, Auger K, Tieder J, Statile A, Jerardi K, McClain L, Shah S.: Prevalence of bacteremia in hospitalized
pediatric patients with community-acquired pneumonia. Pediatr Infect Dis J 2013;32:736-40. doi: 10.1097/INF.0b013e318290bf63.
23 McCulloh R, Koster M, Yin D, Milner T, Ralston S, Hill V, Alverson B, Biondi E.: Evaluating the use of blood cultures in the management
of children hospitalized for community-acquired pneumonia. PLoS One 2015;10:e0117462. doi: 10.1371/journal.pone.0117462.
24 Selva L, Benmessaoud R,Lanaspa M, Jroundi I, Moraleda C, Acacio S, Iñigo M, Bastiani A, Monsonis M, Pallares R, Bassat Q, Muñoz-Almagro C:
Detection of Streptococcus pneumoniae and Haemophilus influenzae type B by real-time PCR from dried blood spot samples among children
with pneumonia: a useful approach for developing countries. PLoS One 2013;8:e76970. doi: 10.1371/journal.pone.0076970.
25 Ybanez S, Garcia R.: Prevalence and factors associated with bacteremia in pediatric community-acquired pneumonia in a private tertiary
hospital in Makati from May 2009 to April 2014. Philippine Pediatric Society,Inc. Abstracts Philippine Pediatric Researches 2012-2015.
26 Esposito S, Marchese A, Tozzi A, Rossi G, Da Dalt L, Bona G, Pelucchi C, Schito G, Principi N; Italian Pneumococcal CAP Group:
Bacteremic pneumococcal community-acquired pneumonia in children less than 5 years of age in Italy. Pediatr Infect Dis J 2012;31:705-10.
27 Chisti M, Ahmed T, Ashraf H, Faruque A, Bardhan P, Dey S, Huq S, Das S, Salam M.:Clinical predictors and outcome of metabolic
acidosis in under-five children admitted to an urban hospital in Bangladesh with diarrhea and pneumonia. PLoS One. 2012;7:e39164.
28 Wang L, Mu S, Lin C, Lin M, Sung T.: Fatal community-acquired pneumonia: 18 years in a medical center. Pediatr Neonatol 2013;54:22-7.
29 Glatstein M, Rozen R, Scolnik D, Rimon A, Grisaru-Soen G, Freedman S, Reif S.: Radiologic predictors of hyponatremia in children
hospitalized with community-acquired pneumonia. Pediatr Emerg Care 2012;28:764-6.
30 Wrotek A, Jackowska T. Hyponatremia in children hospitalized due to pneumonia. Adv Exp Med Biol 2013;788:103-8.
31 Chisti M, Ahmed T, Ashraf H, Faruque AS, Bardhan P, Dey S, Huq S, Das S, Salam M.: Clinical predictors and outcome of metabolic
acidosis in under-five children admitted to an urban hospital in Bangladesh with diarrhea and pneumonia. PLoS One 2012;7:e39164. doi:
10.1371/journal.pone.0039164.
32 McClain L, Hall M, Shah S, Tieder J, Myers AL, Auger K, Statile A, Jerardi K, Queen M, Fieldston E, Williams D.: Admission chest
radiographs predict illness severity for children hospitalized with pneumonia. J Hosp Med. 2014 ;9:559-64.
33 Basnet S, Sharma A, Mathisen M, Shrestha P, Ghimire R, Shrestha D, Valentiner-Branth P, Sommerfelt H, Strand T.: Predictors of
duration and treatment failure of severe pneumonia in hospitalized young Nepalese children. PLoS One 2015;10:e0122052.
34 Jain DL, Sarathi V, Jawalekar S.: Predictors of treatment failure in hospitalized children [3-59 months] with severe and very severe
pneumonia. Indian Pediatr 2013;50:787-9
35 Wrotek A, Jackowska T.: Hyponatremia in children hospitalized due to pneumonia. Adv Exp Med Biol 2013;788:103-8.
36 Williams D, Hall M, Auger K,Tieder J, Jerardi K, Queen M, Statile A, Myers A, Shah S.: Association of White Blood Cell Count and C-
Reactive Protein with Outcomes in Children Hospitalized with Community- Acquired Pneumonia. Pediatr Infect Dis J 2015;34:792–793.

Clinical Question 5. When is antibiotic recommended?


1 Wei L, Liu W, Zhang X, Liu E, Wo Y, Cowling B, Cao W.: Detection of viral and bacterial pathogens in hospitalized children with acute
respiratory illnesses, Chongqing, 2009-2013. Medicine (Baltimore). 2015;94:e742. doi: 10.1097/MD.0000000000000742.
2 Kurz H, Göpfrich H, Huber K, Krugluger W, Asbott F, Wabnegger L, Apfalter P, Sebesta C.: Spectrum of pathogens of in-patient children
and youths with community acquired pneumonia: a 3 year survey of a community hospital in Vienna, Austria. Wien Klin Wochenschr.
2013;125(21-22):674-9. doi:10.1007/s00508-013-0426-z.
3 Peng Y, Shu C, Fu Z, Li QB, Liu Z, Yan L.: Pathogen detection of 1  613 cases of hospitalized children with community acquired pneumonia
Zhongguo Dang Dai Er Ke Za Zhi. 2015;17:1193-9.
4 Jain S, Williams D, Arnold S, Ampofo K, Bramley A, Reed C, Stockmann C, Anderson E, Grijalva C, Self W, Zhu Y, Patel A, Hymas W,
Chappell J, Kaufman R, Kan J, Dansie D, Lenny N, Hillyard D, Haynes L, Levine M, Lindstrom S, Winchell J, Katz J, Erdman D,
Schneider E, Hicks LA, Wunderink R, Edwards K, Pavia A, McCullers J, Finelli L; CDC EPIC Study Team.: Community-acquired
pneumonia requiring hospitalization among U.S. children N Engl J Med. 2015; 372:835-45. doi: 10.1056/NEJMoa1405870.
6 Lagare A, Maïnassara HB, Issaka B, Sidiki A, Tempia S.: Viral and bacterial etiology of severe acute respiratory illness among children  <  5
years of age without influenza in Niger. BMC Infect Dis 2015;15:515. doi: 10.1186/s12879-015-1251-y.

39
7 Elemraid M, Sails A, Eltringham G, Perry J, Rushton S, Spencer D, Thomas M, Eastham K, Hampton F, Gennery A, Clark J; North East of
England Paediatric Respiratory Infection Study Group.: Aetiology of paediatric pneumonia after the introduction of pneumococcal
conjugate vaccine. Eur Respir J 2013;42:1595-603. doi:10.1183/09031936.00199112.
8 Chen C, Lin P, Tsai M, Huang C, Tsao K, Wong K, Chang L, Chiu C, Lin T, Huang Y.: Etiology of community-acquired pneumonia in
hospitalized children in northern Taiwan. Pediatr Infect Dis J. 2012;31:e196-201. doi:10.1097/INF.0b013e31826eb5a7.
9 Mathew J, Singhi S, Ray P, Hagel E, Saghafian-Hedengren S, Bansal A, Ygberg S, Sodhi K, Kumar B, Nilsson A.: Etiology of community
acquired pneumonia among children in India: prospective, cohort study. J Glob Health 2015;5:050418.doi:10.7189/jogh.05.020418.
10 Honkinen M, Lahti E, Österback R, Ruuskanen O, Waris M.Viruses and bacteria in sputum samples of children with community-acquired
pneumonia Clin Microbiol Infect. 2012;18:300-7.doi:10.1111/j.1469-0691.2011.03603.
11 Banstola A.: The epidemiology of hospitalization for pneumonia in children under five in the rural western region of Nepal: a descriptive
study. PLoS One 2013; 8:e71311.doi:10.1371/journal.pone.0071311.
12 Elemraid M, Rushton S, Thomas M, Spencer D, Gennery A, Clark J.: Utility of inflammatory markers in predicting the aetiology of
pneumonia in children Diagn Microbiol Infect Dis. 2014;79:458-62.doi:10.1016/j.diagmicrobio.2014.04.006.
13 Galetto-Lacour A, Alcoba G, Posfay-Barbe KM, Cevey-Macherel M, Gehri M, Ochs M, Brookes R, Siegrist C, Gervaix A.: Elevated
inflammatory markers combined with positive pneumococcal urinary antigen are a good predictor of pneumococcal community-
acquired pneumonia in children. Pediatr Infect Dis J 2013;32:1175-9.doi:10.1097/INF.0b013e31829ba62a.
14 Hoshina T, Nanishi E, Kanno S, Nishio H, Kusuhara K, Hara T.: The utility of biomarkers in differentiating bacterial from non-bacterial
lower respiratory tract infection in hospitalized children: difference of the diagnostic performance between acute pneumonia and
bronchitis. J Infect Chemother 2014;20:616-20. doi:10.1016/j.jiac.2014.06.003.
15 Gao J, Yue B, Li H, Chen R, Wu C, Xiao M.: Epidemiology and clinical features of segmental/lobar pattern Mycoplasma pneumoniae
pneumonia: A ten-year retrospective clinical study. Exp Ther Med 2015;10:2337-2344.
16 Nascimento-Carvalho C, Araújo-Neto C, Ruuskanen O.: Association between bacterial infection and radiologically confirmed pneumonia
among children. Pediatr Infect Dis J 2015;34:490-3.doi:10.1097/INF.0000000000000622.
17 Bekdas M, Goksugur S, Sarac E, Erkocoglu M, Demircioglu F.: Neutrophil/lymphocyte and C-reactive protein/mean platelet volume ratios
in differentiating between viral and bacterial pneumonias and diagnosing early complications in children. Saudi Med J 2014;35:442-7.

Clinical Question 6. What empiric treatment should be administered if a bacterial etiology is strongly considered?
1 Gentile A, Bardach A, Ciapponi A, Garcia-Marti S, Aruj P, Glujovsky D, Calcagno J, Mazzoni A, Colindres R.: Epidemiology ofcommunity-
acquired pneumonia in children of Latin America and the Caribbean: a systematic review and meta-analysis. Int J Infect Dis 2012;16:e5-
15. doi:10.1016/j.ijid.2011.09.013.
2 Vong S, Guillard B, Borand L, Rammaert B, Goyet S, Te V, Try P, Hem S, Rith S, Ly S, Cavailler C, Mayaud C, Buchy P.: Acute lower
respiratory infections in ≥5 year-old hospitalized patients in Cambodia, a low-income tropical country: clinical characteristics and
pathogenic etiology. BMC Infectious Diseases 2013 13:97.
3 Peng Y, Shu C, Fu Z, Li QB, Liu Z, Yan L.:Pathogen detection of 1  613 cases of hospitalized children with community acquired pneumonia.
Zhongguo Dang Dai Er Ke Za Zhi. 2015;17:1193-9.
4 Honkinen M, Lahti E, Österback R, Ruuskanen O, Waris M.Viruses and bacteria in sputum samples of children with community-acquired
pneumonia. Clin Microbiol Infect. 2012;18:300-7.doi:10.1111/j.1469-0691.2011.03603.
5 Antimicrobial Resistance Surveillance Reference Laboratory, Antimicrobial Resistance Surveillance Program 2012 Annual Report. Manila,
Philippines;2012.
6 Antimicrobial Resistance Surveillance Reference Laboratory, Antimicrobial Resistance Surveillance Program 2013 Annual Report. Manila,
Philippines;2013.
7 Antimicrobial Resistance Surveillance Reference Laboratory, Antimicrobial Resistance Surveillance Program 2014 Annual Report. Manila,
Philippines;2014.
8 Antimicrobial Resistance Surveillance Reference Laboratory, Antimicrobial Resistance Surveillance Program 2015 Annual Report. Manila,
Philippines;2015.
9 Lodha R, Kabra S, Pandey R.: Antibiotics for community-acquired pneumonia in children. Cochrane Database Syst Rev 2013;(6):
CD004874.doi:10.1002/14651858.CD004874.pub4.
10 Ambroggio L, Test M, Metlay J, Graf T, Blosky M, Macaluso M, Shah S.: Comparative Effectiveness of Beta-lactam Versus Macrolide
Monotherapy in Children with Pneumonia Diagnosed in the Outpatient Setting. Pediatr Infect Dis J 2015;34:839-42. doi:
10.1097/INF.0000000000000740.
11 Greenberg D, Givon-Lavi N, Sadaka Y, Ben-Shimol S, Bar-Ziv J, Dagan R.: Short-course antibiotic treatment for community-acquired
alveolar pneumonia in ambulatory children: a double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J 2014;33:136-42. doi:
10.1097/INF.000000000000002
12 Florendo S.: Clinical efficacy of 3-day, 5-day versus 7-day twice a day regimen of oral amoxicillin in the treatment of non severe
pneumonia in children 11-59 months: a risk stratification clinical trial. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric
Researches 2012-2015.
13 Queen M, Myers A, Hall M, Shah S, Williams D, Auger K, Jerardi K, Statile A, Tieder J.: Comparative effectiveness of empiric antibiotics
for community-acquired pneumonia. Pediatrics 2014;133:e23-9.doi: 10.1542/peds.2013-1773.
14 Williams D, Hall M, Shah S, Parikh K, Tyler A, Neuman M, Hersh A, Brogan T, Blaschke A, Grijalva C.: Narrow vs broad-spectrum
antimicrobial therapy for children hospitalized with pneumonia. Pediatrics 2013;132:e1141-8. doi: 10.1542/peds.2013-1614.
15 Dinur-Schejter Y.: Antibiotic treatment of children with community-acquired pneumonia: comparison of penicillin or ampicillin versus
cefuroxime Pediatr Pulmonol. 2013;48:52-8. doi: 10.1002/ppul.22534.
16 Das R, Singh M.: Treatment of severe community-acquired pneumonia with oral amoxicillin in under-five children in developing country: a
systematic review. PLoS One 2013;25;8:e66232. doi: 10.1371/journal.pone.0066232.
17 Brandão A, Simbalista R, Borges I, Andrade D, Araújo M, Nascimento-Carvalho C.: Retrospective analysis of the efficacies of two
different regimens of aqueous penicillin G administered to children with pneumonia. Antimicrob Agents Chemother 2014;58:1343-7.
doi:10.1128/AAC.01951-13.
18 Patel A, Bang A, Singh M, Dhande L, Chelliah L, Malik A, Khadse S; ISPOT Study Group.: A randomized controlled trial of hospital
versus home based therapy with oral amoxicillin for severe pneumonia in children aged 3 - 59 months: The IndiaCLEN Severe
Pneumonia Oral Therapy (ISPOT) Study. BMC Pediatr 2015;15:186.doi:10.1186/s12887-015-0510-9.

40
19 Leyenaar J, Shieh M, Lagu T, Pekow P, Lindenauer P.: Comparative effectiveness of ceftriaxone in combination with a macrolide
compared with ceftriaxone alone for pediatric patients hospitalized with community-acquired pneumonia. Pediatr Infect Dis J
2014;33:387-92. doi: 10.1097/INF.0000000000000119.
20 Amarilyo G, Glatstein M, Alper A, Scolnik D, Lavie M, Schneebaum N, Grisaru-Soen G, Assia A, Ben-Sira L, Reif S.: IV Penicillin G is as
effective as IV cefuroxime in treating community-acquired pneumonia in children. Am J Ther 2014;21:814.doi:10.1097/MJT.
0b013e3182459c28.
21 Agweyu A, Gathara D, Oliwa J, Muinga N, Edwards T, Allen E, Maleche-Obimbo E, English M. Severe Pneumonia Study Group.
Collaborators.: Aweyo F, Awuonda B, Chabi M, Isika N, Kariuki M, Kuria M, Mandi P, Masibo L, Massawa T, Mogoa W, Mutai B, Muriithi G,
Ng'arng'ar S, Nyamai R, Okello D, Oywer W, Wanjala L.: Oral amoxicillin versus benzyl penicillin for severe pneumonia among Kenyan
children: a pragmatic randomized controlled noninferiority trial. Clin Infect Dis 2015;60:1216-24. doi: 10.1093/cid/ciu1166.

Clinical Question 7. What treatment should be initially given if a viral etiology is strongly considered?
1 American Academy of Pediatrics, Committee on Infectious Diseases: Recommendations for prevention and control of influenza in children,
2015–2016. Pediatrics 2015;136(4).doi:10.1542/peds.2015-2920.
2 Jefferson T, Jones M, Doshi P, Del Mar C, Hama R, Thompson M, Spencer E, Onakpoya I, Mahtani K, Nunan D, Howick J,
Heneghan C.: Neuraminidase inhibitors for preventing and treating influenza in adults and children (Review). Cochrane Database
Syst Rev 2014;4:CD008965.
3 Kimberlin D, Acosta E, Prichard M, Sanchez P, Ampofo K, Lang D, Ashouri N, Vanchiere J, Abzug M, Abughali N, Caserta M,
Englund J, Sood S, Spigarelli M, Bradley J, Lew J, Michaels M, Wan W, Cloud G, Jester P, Wakeman F and Whitley R,
for the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group.: Oseltamivir pharmacokinetics,
dosing, and resistance among children aged <2 years with influenza. J Infect Dis. 2013;207(5): 709–720. doi: 10.1093/infdis/jis765.
4 Perez C.: Prevalence of viral pathogens among paediatric patients admitted for pneumonia in a local tertiary hospital. Pediatric Infectious
Disease Society of the Philippines Journal 2012;13:8-14.
5 Suzuki A, Lupisan S, Furuse Y, Fuji N, Saito M, Tamaki R, Galang H, Sombrero L, Mondoy M, Aniceto R, Olveda R, Oshitani H.:
Respiratory viruses from hospitalized children with severe pneumonia in the Philippines. BMC Infect Dis. 2012;12:267.doi:
10.1186/1471-2334-12-267.
6 Wang M, Cai F, Wu X, Wu T, Su X, Shi Y.: Incidence of viral infection detected by PCR and real-time PCR in childhood community-
acquired pneumonia: A meta-analysis. Respirology 2015; 20: 405-412. doi: 10.1111/resp.12472.
7 Self W, Griffin M, Zhu Y, Dupont W, Barrett T, Grijalva C.: The high burden of pneumonia on US emergency departments during the 2009
influenza pandemic. J Infect. 2014; 68(2):156-64. doi:10.1016/j.jinf.2013.10.005.

Clinical Question 8. When can a patient be considered as responding to the current antibiotic?
1 Wolf R, Edwards K, Grijalva C, Self W, Zhu Y, Chappell J, Bramley A, Jain S, Williams D.:Time to clinical stability among children
hospitalized with pneumonia. J Hosp Med 2015;10:380-3. doi: 10.1002/jhm.2370.
2 Izadnegahdar R, Fox M, Thea D, Qazi S.: Pneumonia Studies Group. Frequency and trajectory of abnormalities in respiratory rate, tempera-
ture and oxygen saturation in severe pneumonia in children. Pediatr Infect Dis J 2012;31:8635.doi:10.1097/INF.0b013e318257f8ec.

Clinical Question 9. What should be done if a patient is not responding to current antibiotic therapy?
1 Agweyu A, Kibore M, Digolo L, Kosgei C, Maina V, Mugane S, Muma S, Wachira J, Waiyego M, Maleche-Obimbo E.: Prevalence and
correlates of treatment failure among Kenyan children hospitalized with severe community-acquired pneumonia: a prospective study of the
clinical effectiveness of WHO pneumonia case management guidelines. Trop Med Int Health 2014;19:1310-20.doi: 10.1111/tmi.12368.
2 Webb C, Ngama M, Ngatia A, Shebbe M, Morpeth S, Mwarumba S, Bett A, Nokes D, Seale A, Kazungu S, Munywoki P, Hammitt LL,
Scott J, Berkley J.: Treatment failure among Kenyan children with severe pneumonia--a cohort study. Pediatr Infect Dis J.
2012;31:e152-7.doi:10.1097/INF.0b013e3182638012.
3 Basnet A, Sharma A, Mathisen M, Shrestha P, Ghimire R, Shrestha D, Valentiner-Branth P, Sommerfelt H, Strand T.: Predictors of
duration and treatment failure of severe pneumonia in hospitalized young Nepalese children PLoS One 2015;10:e0122052.doi:
10.1371/journal.pone.0122052.eCollection 2015.
4 Jain D, Sarathi V, Jawalekar S.: Predictors of treatment failure in hospitalized children [3-59 months] with severe and very severe
pneumonia. Indian Pediatr 2013;50:787-9.

Clinical Question 10. When can switch therapy in bacterial pneumonia be started?
In-iw S, Winijkul G, Sonjaipanich S, Manaboriboon B.: Comparison between the Efficacy of Switch Therapy and Conventional Therapy in
Pediatric Community-Acquired Pneumonia. J Med Assoc Thai 2015;98:858-63.

Clinical Question 11. What ancillary treatment can be given?


1 Rojas-Reyes M, Granados Rugeles C, Charry-Anzola L.: Oxygen therapy for lower respiratory tract infections in children between 3 months and
15 years of age. Cochrane Database of Systematic Reviews 2014,Issue 12.Art.No.: CD005975.DOI:10.1002/14651858.CD005975.pub3.
2 Chisti M, Salam M, Smith J, Ahmed T, Pietroni M, Shahunja K, Shahid A, Faruque A, Ashraf H, Bardhan P, Sharifuzzaman, Graham S,
Duke T.: Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open,
randomised controlled trial Lancet. 2015;386:1057-65. doi:10.1016/S0140-6736(15)60249-5.
3 Srinivasan M, Ndeezi G, Mboijana C, Kiguli S, Bimenya G, Nankabirwa V, Tumwine J.: Zinc adjunct therapy reduces case fatality in severe
childhood pneumonia: a randomized double blind placebo-controlled trial. BMC Med 2012;10:14.doi:10.1186/1741-7015-10-14.
4 Rulloda M.: Zinc as adjunct therapy for treating pneumonia in children 6 months old to 5 years of age: a 3 month prospective, randomized,
double blind, placebo-controlled trial. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
5 Justina M.: Use of systemic corticosteroid as adjunct therapy among hospitalized children with community-acquired pneumonia. Philippine
Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
6 Guinto M.: Efficacy of zinc as an adjunct to amoxicillin in the treatment of nonsevere pneumonia in children 6 months to 5 years old at
Angeles University Foundation Medical Center Philippine. Pediatric Society,Inc. Abstracts Philippine Pediatric Researches 2012-2015.
7 Chang C, Cheng A, Chang A.: Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children
and adults. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD006088. DOI:10.1002/14651858.CD006088.pub4.

41
8 Ambroggio L, Test M, Metlay J, Graf T, Blosky M, Macaluso M, Shah S.: Adjunct Systemic Corticosteroid Therapy in Children With
Community-Acquired Pneumonia in the Outpatient Setting. J Pediatric Infect Dis Soc 2015 ;4:21-7. doi:10.1093/jpids/piu017.
9 Chaves G, Fregonezi G, Dias F, Ribeiro C, Guerra R, Freitas D, Parreira V, Mendonca K.: Chest physiotherapy for pneumonia in children.
Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD010277. DOI: 10.1002/14651858.CD010277.pub2.
10 Das R, Singh M, Panigrahi I, Naik S.: Vitamin d supplementation for the treatment of acute childhood pneumonia: a systematic review.
ISRN Pediatr. 2013;2013:459160. doi: 10.1155/2013/459160. eCollection2013.
11 Doctor-Bernabe J, Ampil I, Bibera G.: Effect of zinc supplementation as an adjunct in the treatment of pneumonia in children ages 2 to 59
months: a meta-analysis. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
12 Macalino MV, Dans L, Lorenzana R.: Zinc as adjunct to antibiotics in the treatment of severe pneumonia in children aged two months to
five years: a meta-analysis. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
13 Wadhwa N, Chandran A, Aneja S, Lodha R, Kabra S, Chaturvedi M, Sodhi J, Fitzwater S, Chandra J, Rath B, Kainth U, Saini S, Black R,
Santosham M, Bhatnagar S.: Efficacy of zinc given as an adjunct in the treatment of severe and very severe pneumonia in hospitalized
children 2-24 mo of age: a randomized, double-blind, placebo-controlled trial. Am J Clin Nutr 2013;97:1387-
94.doi:10.3945/ajcn.112.052951.
14 Sempértegui, Estrella B, Rodríguez O, Gómez D, Cabezas M, Salgado G, Sabin L, Hamer D.: Zinc as an adjunct to the treatment of severe
pneumonia in Ecuadorian children: a randomized controlled trial. Am J Clin Nutr 2014;99:497-505.doi: 10.3945/ajcn.113.067892.
15 Shah G, Dutta A, Shah D, Mishra O.: Role of zinc in severe pneumonia: a randomized double bind placebo controlled study. Ital J Pediatr
2012;38:36. doi: 10.1186/1824-7288-38-36.
16 Srinivasan M, Ndeezi G, Mboijana C, Kiguli S, Bimenya G, Nankabirwa V and Tumwine J.: Zinc adjunct therapy reduces case fatality in
severe childhood pneumonia: a randomized double blind placebo-controlled trial. Medicine 2012;10:14.
17 Fataki M, Kisenge R, Sudfeld C, Aboud S, Okuma J, Mehta S, Spiegelman D, Fawzi W.: Effect of zinc supplementation on duration of
hospitalization in Tanzanian children presenting with acute pneumonia. J Trop Pediatr 2014;60:104-11.doi:10.1093/tropej/fmt089.
18 Becina P, Peralta K, Becina G.: A double-blind, randomized, controlled trial of the efficacy of multiple strain probiotics as adjunct therapy
for patients [2 months-4 years old] with moderate risk community-acquired pneumonia admitted at National Children’s Hospital.
Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
19 Villanueva J, Matheus J.: A randomized controlled trial on the effects of oral folate in the treatment of pediatric community-acquired
pneumonia-c among infants ages 2-12 months admitted at the pediatric ward of Dr. Jose Fabella Memorial Hospital. Philippine
Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
20 Mondragon A.: The efficacy of oral vitamin D3 supplementation on the severity of pneumonia in children ages 3 months – 60 months: a
randomized double-blind controlled trial. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
21 Martinez M.:The efficacy of acetylcysteine nebulization as an adjunct therapy for community-acquired pneumonia-C in children aged 3 to 60
months admitted at a tertiary government hospital. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
22 Delizo M, Resurreccion E.: Nebulization using normal saline solution or bronchodilators as adjunct treatment in children hospitalized with
community-acquired pneumonia: a retrospective study Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
23 Dalangin B.: A randomized controlled trial on the efficacy and safety of probiotic [Bacillus claushii] and zinc as adjuncts in the treatment
of pediatric community-acquired pneumonia among 1 to 10 years old in an outpatient department at a private hospital. Philippine
Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
24 Dionisia-Delfin,T.:The effectiveness of spirulina as an adjunct in the treatment of pediatric community-acquired pneumonia C among children
aged 2-5 years: a randomized placebo controlled trial. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.
25 Vierneza M.: The effectiveness of virgin coconut oil as adjunct treatment of pediatric community acquired pneumonia: a randomized
controlled trial. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric Researches 2012-2015.

Clinical Question 12. How can pneumonia be prevented?


1 Field Health and Information Services Annual Report 2012. Department of Health National Epidemiology Center Public Health Surveillance
and Informatics Division Manila, Philippines.
2 Field Health and Information Services Annual Report 2013. Department of Health National Epidemiology Center Public Health Surveillance
and Informatics Division Manila, Philippines.
3 Field Health and Information Services Annual Report 2014. Department of Health National Epidemiology Center Public Health Surveillance
and Informatics Division Manila, Philippines.
4 ICD 10 Registry, Committee on Registry of Childhood Disease, Philippine Pediatric Society, Inc.
5 Liu L, Oza S, Hogan D, Perin J, Rudan I , Lawn J, Cousens S , Mathers C, Black R.: Global, regional, and national causes of child mortality
in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015;385:430-40. doi:
10.1016/S0140-6736(14)61698-6.
6 Tumanan-Mendoza B, Mendoza V, Punzalan F, Reganit P, Bacolcol S.: Economic Burden of Community-Acquired Pneumonia among
Adults in the Philippines: Its Equity and Policy Implications in the Case Rate Payments of the Philippine Health Insurance Corporation.
Value in Health Regional Issues 6C; 2015;118–125
7 Moore M, Link-Gelles R, Schaffner W, Lynfield R, Lexau C, Bennett N, Petit S, Zansky S, Harrison L, Reingold A, Miller L, Scherzinger K,
Thomas A, Farley M, Zell E, Taylor T, Pondo T, Rodgers L, McGee L, Beall B, Jorgensen J, Whitney CG.: Effect of use of 13-valent
pneumococcal conjugate vaccine in children on invasive pneumococcal disease in children and adults in the USA: analysis of multisite,
population-based surveillance. Lancet Infect Dis 2015;15:301-9.doi:10.1016/S1473-3099(14)71081-3.
8 Simonsen L, Taylor R, Schuck-Paim C, Lustig R, Haber M, Klugman K.:Effect of 13-valent pneumococcal conjugate vaccine on admissions
to hospital 2 years after its introduction in the USA: a time series analysis Lancet Respir Med. 2014;2:387-94. doi: 10.1016/S2213-
2600(14)70032-3.
9 Pírez M, Algorta G, Chamorro F, Romero C, Varela A, Cedres A, Giachetto G.: Changes in hospitalizations for pneumonia after universal
vaccination with pneumococcal conjugate vaccines 7/13 valent and haemophilus influenzae type b conjugate vaccine in a Pediatric
Referral Hospital in Uruguay. Pediatr Infect Dis J 2014;33:753-9. doi:10.1097/INF.0000000000000294.
10 Gentile Á, Juarez Mdel V, Luciön M, Romanin V, Giglio N, Bakin J. Influence of respiratory viruses on the evaluation of the 13-valent
pneumococcal conjugate vaccine effectiveness in children under 5 years old: A time-series study for the 2001-2013 period. Arch Argent
Pediatr 2015;113:310-6. doi:10.1590/S0325-00752015000400006
11 Bruce M, Singleton R, Bulkow L, Rudolph K, Zulz T, Gounder P, Hurlburt D, Bruden D, Hennessy T.: Impact of the 13-valent
pneumococcal conjugate vaccine (pcv13) on invasive pneumococcal disease and carriage in Alaska Vaccine. 2015;33:4813-9. doi:
10.1016/j.vaccine.2015.07.080.

42
12 Martinelli D, Pedalino B, Cappelli M, Caputi G, Sallustio A, Fortunato F, Tafuri S, Cozza V, Germinario C, Chironna M, Prato R; Apulian
Group for the surveillance of pediatric IPD.: Towards the 13-valent pneumococcal conjugate universal vaccination: effectiveness in the
transition era between PCV7 and PCV13 in Italy, 2010-2013. Hum Vaccin Immunother 2014;10:33-9. doi:10.4161/hv.26650.
13 Saxena S, Atchison C, Cecil E, Sharland M, Koshy E, Bottle A.: Additive impact of pneumococcal conjugate vaccines on pneumonia and
empyema hospital admissions in England. J Infect 2015;71:428-36. doi: 10.1016/j.jinf.2015.06.011.
14 Griffin M, Mitchel E, Moore M, Whitney C, Grijalva C; Centers for Disease Control and Prevention (CDC).: Declines in pneumonia
hospitalizations of children aged <2 years associated with the use of pneumococcal conjugate vaccines -Tennessee,1998-2012.
MMWR Morb Mortal Wkly Rep. 2014;63:995-8
15 Greenberg D, Givon-Lavi N, Ben-Shimol S, Ziv JB, Dagan R.: Impact of PCV7/PCV13 introduction on community-acquired alveolar
pneumonia in children <5 years. Vaccine 2015;33(36):4623-9. doi: 10.1016/j.vaccine.2015.06.062.
16 Abrão W, de Mello L, da Silva A. Nunes A.: Impact of the antipneumococcal conjugate vaccine on the occurrence of infectious respiratory
diseases and hospitalization rates in children. Rev Soc Bras Med Trop 48:44-49.
17 Afonso E, Minamisava R, Bierrenbach A, Escalante J, Alencar A, Domingues C, Morais-Neto O, Toscano C, Andrade A.: Effect of 10-
valent pneumococcal vaccine on pneumonia among children. Brazil Emerg Infect Dis 2013;19:589-97. doi:10.3201/eid1904.121198.
18 Tregnaghi M, Sáez-Llorens X, López P, Abate H, Smith E, Pósleman A, Calvo A, Wong D, Cortes-Barbosa C, Ceballos A, Tregnaghi M,
Sierra A, Rodriguez M,Troitiño M, Carabajal C, Falaschi A, Leandro A, Castrejón M, Lepetic A, Lommel P, Hausdorff WP, Borys D, Ruiz
Guiñazú J, Ortega-Barría E, Yarzábal JP, Schuerman L; COMPAS Group.: Efficacy of pneumococcal nontypable Haemophilus influenza
protein D conjugate vaccine (PHiD-CV) in young Latin American children: A double-blind randomized controlled trial. PLoS Med. 2014;
11:e1001657.doi:10.1371/journal.pmed.1001657. Erratum in: PLoS Med. 2015;12:e1001850.
19 Flasche S, Takahashi K, Vu D, Suzuki M, Nguyen T, Le H, Hashizume M, Dang D, Edmond K, Ariyoshi K, Mulholland EK, Edmunds W,
Yoshida L.: Early indication for a reduced burden of radiologically confirmed pneumonia in children following the introduction of routine
vaccination against Haemophilus influenzae type b in Nha Trang, Vietnam.Vaccine 2014;32:6963-70. doi:10.1016/j.vaccine.2014.10.055.
20 Ekaru H, Mbarak N, Shurie S, Kosgei E, Oyungu E, Kwena A.: Community acquired pneumonia among children admitted in a tertiary
hospital: the burden and related factors. East Afr Med J 2012;89:301-5.
21 Grant C, Emery D, Milne T, Coster G, Forrest C, Wall C, Scragg R, Aickin R, Crengle S, Leversha A, Tukuitonga C, Robinson E.: Risk
factors for community-acquired pneumonia in pre-school-aged children. J Paediatr Child Health 2012;48:402-12. doi:10.1111/j.1440-
1754.2011.02244.x.
22 Tomas A, Resurreccion M.: A hospital based case control study on the association of selected maternal risk taking behaviors in the
development of community-acquired pneumonia among infants. Philippine Pediatric Society, Inc. Abstracts Philippine Pediatric
Researches 2012-2015.
23 Barsam F, Borges G, Severino A, de Mello L, da Silva A, Nunes A.: Factors associated with community-acquired pneumonia in
hospitalised children and adolescents aged 6 months to 13 years old. Eur J Pediatr 2013;172:493-9. doi:10.1007/s00431-012-1909-
z.
24 Ásbjörnsdóttir KH, Slyker JA, Weiss NS, Mbori-Ngacha D, Maleche-Obimbo E Wamalwa D, John-Stewart G.: Breastfeeding is associated
with decreased pneumonia incidence among HIV-exposed, uninfected Kenyan infants. AIDS. 2013;27:2809-15. doi:
10.1097/01.aids.0000432540.59786.6d.
25 Fu W, Ding L-R, Zhuang C, Zhou Y-H (2013) Effects of Zinc Supplementation on the Incidence of Mortality in Preschool Children: A Meta-
Analysis of Randomized Controlled Trials. PLoS ONE 2013;8:e79998. doi:10.1371/journal.pone.0079998
26 Larkin A, Lassetter J.: Vitamin D deficiency and acute lower respiratory infections in children younger than 5 years: identification and
treatment. J Pediatr Health Care 2014;28:572-82; quiz 583-4. doi:10.1016/j.pedhc.2014.08.013

43
APPENDIX. Summary recommendations of 2004 Clinical Practice Guideline in
the Evaluation and Management of Pediatric Community-acquired Pneumonia,
and 2008 1st PAPP Update in the Evaluation and Management of Pediatric
Community-acquired Pneumonia.
CQ 1. WHO SHALL BE CONSIDERED AS HAVING COMMUNITY ACQUIRED PNEUMONIA?

2004 SUMMARY RECOMMENDATION.


Predictors of community-acquired pneumonia in a patient with cough
1. for ages 3 months to 5 years are tachypnea and/or chest indrawing [Recommendation Grade B].
2. for ages 5 to 12 years are fever, tachypnea, and crackles [Recommendation Grade D].
3. beyond 12 years of age are the presence of the following features [Recommendation Grade D]: 3.1. fever, tachypnea, and
tachycardia; and 3.2. at least one abnormal chest findings of diminished breath sounds, rhonchi, crackles or wheezes.

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.


The likelihood of radiologic pneumonia at the Emergency Room in a patient with cough is highest at ages 3 months to 5 years if any of the
following is present: [a] RR>50/min,nasal flaring,and oxygen saturation<96%; or [b] tachypnea and chest indrawing; or [c]chest indrawing.

CQ 2. WHO WILL REQUIRE ADMISSION?

2004 SUMMARY RECOMMENDATION.


1. A patient at moderate to high risk to develop pneumonia-related mortality should be admitted [Recommendation Grade D].
2. A patient at minimal to low risk can be managed on an outpatient basis [Recommendation Grade D].

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.


1. Additional variables for considering admission include lack of measles and Hib vaccination, high oxygen requirement on admission, and
chest indrawing.
2. Admissible patients may be managed in a day care setting.

CQ 3. WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT CLASSIFIED AS


EITHER pCAP A or pCAP B BEING MANAGED IN AN AMBULATORY SETTING?
2004 SUMMARY RECOMMENDATION.
No diagnostic aids are initially requested for a patient classified as either pCAP A or pCAP B who is being managed in an ambulatory
setting [Recommendation Grade D].
2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.
The low risk for bacteremia [1.6% (95% CI 0.7-2.9) among patients aged 2-24 months with nonsevere pneumonia does not warrant blood
culture determination.

CQ 4. WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT CLASSIFIED AS


EITHER pCAP C or pCAP D BEING MANAGED IN A HOSPITAL SETTING?
2004 SUMMARY RECOMMENDATION.
1.The following should be routinely requested: 1.1. Chest x-ray PA-lateral [Recommendation Grade B].
1.2. White blood cell count [Recommendation Grade C].
1.3. Culture and sensitivity of 1.3.1. Blood for pCAP D [Recommendation Grade D].
1.3.2. Pleural fluid [Recommendation Grade D].
1.3.3. Tracheal aspirate upon initial intubation
[Recommendation Grade D].
1.4. Blood gas and/or pulse oximetry [Recommendation Grade D].
2.The following may be requested: culture and sensitivity of sputum for older children [Recommendation Grade D].
3. The following should not be routinely requested: 3.1. Erythrocyte sedimentation rate [Recommendation Grade A].
3.2. C-reactive protein [Recommendation Grade A].

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.


1. Chest radiographic evaluation is primarily utilized as an integral part of a clinical prediction rule in identifying the presence of a bacterial
pathogen. As an individual tool, it can be used to assess severity and presence of complications, and to predict subsequent course of
illness.
2. WBC or CRP has a limited value as an individual test in differentiating bacterial from viral pneumonia. A CRP level [≥ 12 mg/dl] is
associated with necrotizing pneumonia and/or empyema.
3. Single evidence suggests a 63 mm/h value for ESR in predicting the presence of a bacterial pathogen.
4. The microbiologic yield for blood culture ranged from 1.2% to 6.2%.
5. High oxygen requirement on admission is one of the variables associated with mortality.

44
CQ 5. WHEN IS ANTIBIOTIC RECOMMEDED
2004 SUMMARY RECOMMENDATION.
An antibiotic is recommended

1. for a patient classified as either pCAP A or B and is 1.1. beyond 2 years of age [Recommendation Grade B]; or
1.2. having high-grade fever without wheeze [Recommendation Grade D].
2. for a patient classifed as pCAP C and is 2.1. beyond 2 years of age [Recommendation Grade B]; or
2.2. having high-grade fever without wheeze [Recommendation Grade D]; or
2.3. having alveolar consolidation on the chest x-ray [Recommendation Grade B]; or
2.4. having white blood cell count > 15,000 [Recommendation Grade C].
3. for a patient classified as pCAP D [Recommedation D].

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT


1. Epidemiology. 1.1. Recent epidemiologic trend shows that more than 50% of hospitalized cases of pCAP will require antibiotic.
1.2. The importance of mixed infection as causative agents should be clarified as it is responsible for about one-third of
all identified causes of hospitalized pCAP.
2. Microbiologic tests. The yield in detecting bacteremia in pCAP remains to be low at 1.2% to 26%.
3. Predictors of bacterial pathogen. 3.1. A clinical prediction rule that makes use of a bacterial pneumonia score [BPS] of > 4 can predict
the presence of a bacterial pathogen in hospitalized patients aged one month to five years.
3.2. Other individual parameters include the following:
3.2.1. Increasing age generally correlates with the presence of antibiotic-requiring pathogen.
Identifying a specific as to when an antibiotic should be started is difficult.
3.2.2. There is a single evidence in the use of ESR with a value of 63 mm/hr in predicting the
presence of bacterial pathogen.
3.2.3. There is a weak evidence in the use of clinical symptomatology, chest x-ray, WBC and CRP
as predictors of bacterial pathogen.

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


2004 SUMMARY RECOMMENDATION.
1. For a patient classified as pCAP A or pCAP B without previous antibiotic, amoxicillin [40-50 mg/kg/day in 3 divided doses] is the drug of
choice [Recommendation Grade D].
2. For a patient classified as pCAP C without previous antibiotic and who has completed the primary immunization against Haemophilus
influenzae type b, penicillin G [100,000 units/kg/day in 4 divided doses] is the drug of choice [Recommendation Grade D]. If a primary
immunization against Hib has not been completed, ampicillin [100 mg/kg/day in 4 divided doses] should be given [Recommendation Grade D].
3. For a patient classified as pCAP D, a specialist should be consulted [Recommendation Grade D].

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.


1. Epidemiology. 1.1. Epidemiologic trend in developed economies suggests that Streptococcus pneumoniae and Mycoplasma
pneumoniae appear to be the most common pathogens causing community-acquired pneumonia across all ages.
1.2 An important emerging pathogen is community-acquired methicillin-resistant Staphylococcus aureus [CA-MRSA].
2. Antibiotic resistance. Data on 2006 Antimicrobial Resistance Surveillance Program showed resistance rate of less than 10% for
penicillin and chloramphenicol with Streptococcus pneumoniae, and for ampicillin with Haemophilus influenzae.
3. Empiric antibiotic therapy. 3.1. For pCAP A and pCAP B [nonsevere pneumonia], there is evidence for the use of amoxicillin [45 mg/kg/day in
three divided doses] for a minimum duration of 3 days. For those with known hypersensitivity to amoxicillin, a ma-
crolide may be considered. The use of cotrimoxazole is discouraged because of high failure and resistance rates.
3.2. For pCAP C [severe pneumonia], equal efficacies were noted between oral amoxicillin and parenteral
penicillin among patients who can tolerate feeding, and between monotherapy and combination therapy for
those who cannot tolerate feeding. Among monotherapy available for use, ampicillin is the best choice
considering its cost.
3.3. For a patient classified as pCAP D, a specialist should be consulted.

CQ 7. WHAT TREATMENT SHOULD BE INITIALLY GIVEN IF A VIRAL ETIOLOGY IS STRONGLY CONSIDERED?


2004 SUMMARY RECOMMENDATION.
1. Ancillary treatment should only be given [Recommendation Grade D].
2. Oseltamivir [2 mg/kg/dose BID for 5 days] or amantadine [4.4-8.8 mg/kg/day for 3-5 days] may be given for influenza that is either
confirmed by laboratory [Recommendation Grade B] or occurring as an outbreak [Recommendation Grade D].
2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.
Oseltamivir remains to be the drug of choice for laboratory confirmed cases of influenza.

45
CQ 8. WHEN CAN A PATIENT BE CONSIDERED AS RESPONDING TO THE CURRENT ANTIBIOTIC?
2004 SUMMARY RECOMMENDATION.
1. Decrease in respiratory signs [particularly tachypnea] and defervescence within 72 hours after initiation of antibiotic are predictors of
favorable therapeutic response [Recommendation Grade D].
2. Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation [Recommendation Grade B].
3. End of treatment chest x-ray [Recommendation Grade B], WBC, ESR or CRP should not be done to assess therapeutic response to
antibiotic [Recommendation Grade D].
2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.
1. In children with nonsevere pneumonia, clinical index suggestive of good therapeutic response is a respiratory rate >5 breaths/min slower
than baseline recording at the 72nd hour.
2. In children with severe pneumonia, clinical indices suggestive of good therapeutic response are defervescense, decrease in tachypnea
and chest indrawing, increase in oxygen saturation, and ability to feed within 48 hours.

CQ 9. WHAT SHOULD BE DONE IF A PATIENT IS NOT RESPONDING TO CURRENT ANTIBIOTIC THERAPY?


2004 SUMMARY RECOMMENDATION.
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 [Recommendation Grade D]: a. change the initial antibiotic; or b. start an oral macrolide; or c. reevaluate diagnosis.
2. If an inpatient classified as pCAP C is not responding to the current antibiotic within 72 hours, consider consultation with a specialist
because of the following possibilities [Recommendation Grade D]: a. penicillin-resistant Streptococcus pneumoniae; or b. presence
of complications [pulmonary or extrapulmonary]; or c. other diagnosis.
3. If an inpatient classified as pCAP D is not responding to the current antibiotic within 72 hours, consider immediate consultation with a
specialist [Recommendation Grade D].

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.


1. There are no studies dealing with therapeutic interventions following treatment failure among children having CAP.
2. A definition of treatment failure for nonsevere pneumonia is as follows:
a. Same status. This is defined as RR > age-specific range but +5 breaths/min to the baseline reading and without lower chest
indrawing or any danger signs; b. Worse status. This is defined as developing lower chest indrawing or with any of the danger signs.
3. The causes of treatment failure include coinfection with respiratory syncytial virus or mixed infection, non-adherence to treatment for
nonsevere pneumonia, resistance to antibiotics, clinical sepsis, and progressive pneumonia.

CQ 10. WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA BE STARTED?


2004 SUMMARY RECOMMENDATION.
Switch from intravenous antibiotic administration to oral form 2-3 days after initiation of antibiotic is recommended in a patient
[Recommendation Grade D] who 1. is responding to the initial antibiotic therapy; 2. is able to feed with intact gastrointestinal absorption;
and 3. does not have any pulmonary or extrapulmonary complications.

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.


Switch therapy from three [3] days of IV ampicillin to four [4] days of either amoxicillin or cotrimoxazole may be used among patients
admitted because of community acquired pneumonia. Amoxicillin is preferred because of high failure and resistance rates reported in the
use of cotrimoxazole.

CQ 11. WHAT ANCILLARY TREATMENT CAN BE GIVEN?


2004 SUMMARY RECOMMENDATION.

1. Among inpatients, oxygen and hydration should be given if needed [Recommendation Grade D].
2. Cough preparations, chest physiotherapy, bronchial hygiene, nebulization using normal saline solution, steam inhalation, topical
solution, bronchodilators and herbal medicines are not routinely given in community-acquired pneumonia [Recommendation Grade D].
3. In the presence of wheezing, a bronchodilator may be administered [Recommendation Grade D].

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.


1. There is no evidence to support the use of hydration or fluid restriction and cough preparation in the management of pneumonia.
2. The value of elemental zinc or vitamin A is inconclusive.
3. Single study demonstrated benefit for either virgin coconut oil or probiotic as adjunct therapy in pneumonia.
CQ 12. HOW CAN PNEUMONIA BE PREVENTED?
2004 SUMMARY RECOMMENDATION.

1. Vaccines recommended by PPS should be routinely administered to prevent pneumonia [Recommendation Grade B].
2. Zinc supplementation [10 mg for infants and 20 mg for children beyond two years of age given for a total of 4 to 6 months] may be
administered to prevent pneumonia [Recommendation Grade A].
3. Vitamin A [Recommendation Grade A], immunomodulators [Recommendation Grade D] and vitamin C [Recommendation Grade D]
should not be routinely administered as a preventive strategy.

2008 FIRST PAPP UPDATE SUMMARY HIGHLIGHT.


1. A meta-analysis on immunomodulators showed a general reduction of rates in acute respiratory tract infection through the use of
immunostimulants.
2. There are evidences to suggest that handwashing using antibacterial soaps, pneumococcal and Hib vaccination, elemental zinc, and
breastfeeding are effective in preventing pneumonia.
3. Single study showed that patients on gastric acid inhibitors are at an increase risk to have pneumonia.

46

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