Community-Acquired Pneumonia in Children Translated from the original French version published October 2009 This clinical guide is provided for information purposes and is not a substitute for the practitioner’s judgment. GENERAL VIRUS: most frequently involved pathogens in the first 2 years of life Pathogens involved according to child’s age or severity of illness: 1-3 months 1-24 months 2-5 years 6-18 years Afebrile pneumonitis syndrome: • Chlamydia trachomatis • Respiratory syncytial virus and other respiratory viruses • Bordetella pertussis • Respiratory syncytial virus and other respiratory viruses • Streptococcus pneumoniae • Haemophilus influenzae type b* • Nontypeable Haemophilus influenzae • Chlamydia trachomatis • Respiratory viruses • Streptococcus pneumoniae • Nontypeable Haemophilus influenzae • Haemophilus influenzae type b* • Mycoplasma pneumoniae • Chlamydophila† pneumoniae All ages • Mycoplasma Severe pneumonia requiring pneumoniae hospitalization in intensive care unit: • Streptococcus • Streptococcus pneumoniae pneumoniae • Staphylococcus aureus • Chlamydophila† • Streptococcus pyogenes (group A) pneumoniae • Haemophilus influenzae type b* • Influenza viruses A or B • Mycoplasma pneumoniae • Adenovirus and other • Adenovirus respiratory viruses * Unlikely in children who have received at least 3 doses of Haemophilus influenzae type B (Pediacel®) vaccine. † New terminology for Chlamydia pneumoniae. DIAGNOSIS Patients may present the following signs and symptoms: • Cough • Fever • Tachypnea with: s>60 breaths/minute in infants aged <2 months s>50 breaths/minute in infants aged between 2 and 12 months s>40 breaths/minute in toddlers aged 12 months to 5 years s>20 breaths/minute in children aged >5 years • Intercostal, subcostal or supracostal retractions • Presence of crackles • Decreased vesicular breath sounds Higher positive predictive value if more than one sign is present • When combinations of the above signs and symptoms are absent, diagnosis of pneumonia is unlikely (very high negative predictive value). • Chest radiography recommended to confirm the diagnosis. REFERENCES Jadavji T, Law B, Lebel MH, et al. A practical guide for the diagnosis and treatment of pediatric pneumonia. Can Med Assoc J. 1997;156:S703-S711. Low DE, Kellner JD, Allen U, et al. Community-acquired pneumonia in children: a multidisciplinary consensus review. Can J Infect Dis. 2003;14 Suppl B:3B-11B. Vanderkooi OG, Low DE, Green K, et al. Predicting antimicrobial resistance in invasive pneumococcal infections. Clin Infect Dis. 2005 May 1;40(9):1288-97. Please note that other references have been consulted. www.cdm.gouv.qc.ca TREATMENT GUIDELINES • Initial treatment is always empirical. At the present time, no test provides rapid information on the etiology of pneumonia. Treatment suggestions are adapted to the probability of a pathogen in the particular epidemiological context (outpatient or inpatient), underlying comorbidities or severity of the pneumonia. •Prevention: - Smoke-free home - Vaccination: Haemophilus influenzae type b (Pediacel®) vaccine; pneumococcal conjugate vaccine (Prevnar®, Synflorix®) •General care: - Adequate hydration - Analgesic/antipyretic if necessary - Routine use of antitussives not recommended - Oxygen therapy if hypoxemia Potential indications for hospitalization • Age <6 months • Toxic or lethargic appearance • Immunodeficiency • Severe respiratory distress • Oxygen requirement • Underlying cardiac or pulmonary disease • Complicated pneumonia • Dehydration, inability to feed • Vomiting • Failure to respond to oral antibiotics • Low parental involvement to ensure treatment compliance • Factors associated with Streptococcus pneumoniae resistance: - Age <2 years - Use of antibiotics in previous 3 months - Day care attendance - Hospitalization in previous 3 months • If fever persists more than 48 to 72 hours after initiating therapy or if clinical deterioration: reassess the patient and search for complications (empyema). Treatment of community-acquired pneumonia in children according to age Age First-line oral therapy* 1-3 months Afebrile pneumonitis syndrome Clarithromycin (Biaxin®) 15 mg/kg/day ÷ BID x 10 days Azithromycin† (Zithromax®) 10 mg/kg DIE on 1st day then 5 mg/kg/day DIE x 4 days 4 months4 years Amoxicillin‡ 90 mg/kg/day ÷ TID x 7-10 days 5-15 years Clarithromycin (Biaxin®) 15 mg/kg/day ÷ BID x 7-10 days Azithromycin† (Zithromax®) 10 mg/kg DIE on 1st day then 5 mg/kg/day DIE x 4 days Maximum dosage of first-line oral therapy 500 mg BID Second-line oral therapy* Maximum dosage of second-line oral therapy Hospitalize children who are febrile or hypoxic 500 mg DIE day 1 then 250 mg DIE x 4 days 1 500 mg BID 500 mg BID 500 mg DIE day 1 then 250 mg DIE x 4 days Amoxicillin-clavulanate potassium (Clavulin®)§ 90 mg/kg/day ÷ BID or TID x 7-10 days Clarithromycin (Biaxin®) 15 mg/kg/day ÷ BID x 7-10 days Azithromycin† (Zithromax®) 10 mg/kg DIE on 1st day then 5 mg/kg/day DIE x 4 days Cefuroxime axetil (Ceftin®) 30 mg/kg/day ÷ BID x 7-10 days Amoxicillin‡ 90 mg/kg/day ÷ TID x 7-10 days Amoxicillin-clavulanate potassium (Clavulin®)§ 90 mg/kg/day ÷ BID or TID x 7-10 days Cefuroxime axetil (Ceftin®) 30 mg/kg/day ÷ BID x 7-10 days 1 000 mg BID 500 mg BID 500 mg DIE day 1 then 250 mg DIE x 4 days 500 mg BID 1 500 mg BID 1 000 mg BID 500 mg BID * The antibiotics are usually listed in alphabetical order of their generic name. Only one brand name product is listed although several manufacturers may market other brand names. † A Canadian prospective cohort study (Vanderkooi et al, 2005) has shown a significantly lower risk of emergence of macrolide resistance with the use of clarithromycin (Biaxin®, Biaxin Bid® or Biaxin XL®) as compared to azithromycin (Zithromax®). ‡ Amoxicillin 50 mg/kg/day may be used in children without risk factors for antibiotic resistance and who have received the pneumococcal vaccine. § The 7:1 (BID) formulation of amoxicillin-clavulanate potassium (Clavulin®) is preferred because of its better GI tolerance. For certain clinicians, adverse GI effects are lessened with a combination of amoxicillin (45 mg/kg/day) and amoxicillin-clavulanate potassium (45 mg/kg/day). Community-Acquired Pneumonia in Children This guide was developed with the collaboration of the professional corporations (CMQ, OPQ), the federations (FMOQ, FMSQ) and Québec associations of pharmacists and physicians.