Community acquired pneumonia


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Pleural Effusion and Empyema (RCH) 
    Sepsis (VPCN) 
    Sepsis in neonates (Neonatal eHandbook) 

    Key Points

    1. Pneumonia can be diagnosed clinically when there are signs of a lower respiratory tract infection and wheezing syndromes have been ruled out.
    2. Blood tests and microbiological investigations are NOT recommended for routine use in the diagnosis and management of CAP.
    3. CXR does not need to be performed in those with mild disease who will be managed as an outpatient.
    4. For non-severe pneumonia, high dose oral amoxicillin is recommended even for inpatient use.  IV benzylpenicillin can be considered if patient is not tolerating oral intake and not vomiting.  
    5. For infants < 1 month of age see Sepsis in Neonates (Neonatal eHandbook)

    Background

    • Pneumonia can be defined clinically as the presence of persistent or repetitive fever, cough and tachypnoea at rest (and retractions in younger children) when clinical wheezing syndromes have been ruled out.
    • “Complicated pneumonia” occurs when there is a complication such as parapneumonic effusion, empyema, lung abscess, or necrotising pneumonia.  

    Assessment

    History:

    • persistent fever
    • tachypnoea at rest
    • cough
    • increased work of breathing/respiratory distress
    • lethargy/ unwell appearance  

    Examination:

    • hypoxaemia ( <92%) on pulse oximetry
    • crackles and bronchial breathing on auscultation
    • elevated respiratory rate for age
    • chest wall indrawing, retractions, grunting, nasal flaring
    • apnoea
    • absent breath sounds and a dull percussion note suggest a pleural effusion  

    Severity Assessment

    Severe pneumonia should be considered if:

    • There are clinical features of pneumonia and 2 or more of the following:
      • Severe respiratory distress
      • Severe hypoxaemia or cyanosis
      • Marked tachycardia
      • Altered mental state

    OR

    Investigations:

    Investigations including CXR, are NOT recommended for routine use in the diagnosis and management of CAP, particularly in those with mild disease who are expected to be managed as an outpatient.  A CXR (posteroanterior view) is recommended for patients who require admission or if severe or complicated pneumonia is suspected.  

    • U&E may be helpful in identifying hyponatremia secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) and should be done if the child is receiving intravenous fluids. 
    • FBE and blood film may be helpful in sepsis, or severe or complicated disease.
    • Microbiological investigations are generally not needed and should only be considered in children with severe pneumonia or complications:
      • Blood culture
      • Testing for viral pathogens (nasal swabs and nasopharyngeal aspirates for PCR and viral culture)  

    NOTE: Testing for atypical bacteria (including nasopharyngeal secretions and nasal swabs for M.pneumoniae PCR or acute and convalescent serology) is not helpful in guiding management as testing cannot differentiate between asymptomatic carriage and symptomatic infection.

    • Acute phase reactants (particularly CRP) cannot distinguish between a viral or bacterial cause and are not recommended.
    • CXR:
      • Consider repeating during hospital admission if patient fails to clinically improve after 48-72 hrs of appropriate antibiotic therapy.
      • Follow up CXR is not required for those who recover uneventfully but is recommended for those with complicated pneumonia or persistent signs, usually within 4-6 weeks.
      • In those with recurrent pneumonia involving the same lobe or if initial suspicion of a chest mass, anatomical abnormality or foreign body, repeat the CXR in 4-6 weeks.

    Management

    • Admission to hospital is required for oxygenation, fluid therapy or moderate to severe work of breathing.
    • Check oxygen saturations and provide supplemental oxygen if saturations are ≤92%.  Administer oxygen to maintain saturations >92%.
    • If giving NG or IV fluids as maintenance therapy limit fluids to ½ or ⅔ of normal maintenance fluids to avoid fluid overload.
    • Advice regarding antibiotic management is summarised in the algorithm below.  There is good evidence showing the equivalence of oral amoxicillin and IV benzylpenicillin.  

                                                                              

    Antibiotic Management

    Antibiotic management

     

    Penicillin hypersensitivity

    • Please refer to the Therapeutic Guidelines for suggested management of patients reporting hypersensitivity to penicillin.
    • Non-beta-lactam antibiotic alternatives include:
      • Azithromycin 10mg/kg (max 500mg) orally daily instead of oral amoxycillin
      • Vancomycin IV (see local hospital protocol for doses) instead of benzylpenicillin or cefotaxime/ceftriaxone.

    MRSA^ (Methicillin resistant staphylococcus aureus) or CA-MRSA^

    • Consider addition of vancomycin for MRSA in a child if:
      • Concurrent skin infection due to MRSA, OR
      • Indigenous or Torres Strait Islander or Pacific Islander descent, OR
      • Necrotising pneumonia, OR
      • Previous MRSA colonization 

    Influenza

    • Neuraminidase inhibitors (oseltamivir) should be considered for
      • Inpatient with complicated disease thought to be related to influenza
      • Patients requiring ICU admission during influenza season
      • Child with suspected influenza at high risk for complications (such as congenital heart disease, chronic respiratory disease or immunosuppression)    

    Discharge Criteria & Follow up

    Children can be discharged when they are:

    • Maintaining adequate oxygenation
    • Maintaining adequate oral intake  

    When to admit/consult local paediatric team

    • Fulfills criteria for hospital admission
    • Failed outpatient therapy  

    When to consider transfer to tertiary centre

    • Severe or complicated pneumonia
    • Comorbidities such as cardiac disease, chronic respiratory disease, immune deficiency or suppression
    • Children requiring care above the level of comfort of the local hospital
    • Children whose O2 requirement is > FiO2-50%

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Parent information sheet: Pneumonia

    Last revised December, 2016