Site of Care Management Decisions

Hospital

• Children and infants who have moderate to severe CAP as defined by several factors including respiratory distress and hypoxemia (sustained saturation of peripheral oxygen [SpO2] < 90 % at sea level) (Table 2) should be hospitalized for management including skilled pediatric nursing care. (SR-H)
• Infants 3-6 months of age with suspected bacterial CAP are likely to benefit from hospitalization. (SR-L)
• Children and infants with a suspicion or documentation of CAP caused by a pathogen with increased virulence such as community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) should be hospitalized. (SR-L)
• Children and infants for whom there is concern about careful observation at home, who are unable to comply with therapy, or unable to follow-up should be hospitalized. (SR-L)

Intensive Care Unit

• A child should be admitted to an intensive care unit (ICU) if the child requires invasive ventilation via a nonpermanent artificial airway 
  (eg, endotracheal tube). (SR-H)
• A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child acutely requires use of noninvasive positive pressure ventilation (eg, continuous positive airway pressure [CPAP], or bilevel positive airway pressure [BIPAP]). (SR-VL)
• A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has impending respiratory failure. (SR-M)
• A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has sustained tachycardia, inadequate blood pressure or need for pharmacologic support of blood pressure or perfusion. (SR-M)
• A child should be admitted to an ICU if pulse oximetry is < 92% on inspired oxygen of ≥ 0.50. (SR-L)
• A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has altered mental status, whether due to hypercarbia or hypoxia, as a result of pneumonia. (SR-L)
• Severity of illness scores should NOT be used as the sole criteria for ICU admission but should be used in the context of other clinical, laboratory, and radiologic findings. (SR-L)

Diagnostic Testing

Microbiologic Testing

Blood Cultures: Outpatient

• Blood cultures should NOT be routinely performed in nontoxic, fully immunized children with CAP managed in the outpatient setting. (SR-M)
• Blood cultures should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration following initiation of antibiotic therapy. (SR-M)

Blood Cultures: Inpatient

• Blood cultures should be obtained in children requiring hospitalization for presumed bacterial CAP that is moderate to severe, particularly those with complicated pneumonia. (SR-L)
• In improving patients who otherwise meet criteria for discharge, a positive blood culture with identification or susceptibility results pending should NOT routinely preclude discharge of that patient on appropriate oral or intravenous antimicrobial therapy. The patient can be discharged if close follow-up is assured. (WR-L)

Follow-up Blood Cultures

• Repeat blood cultures in children with clear clinical improvement are not necessary to document resolution of pneumococcal bacteremia. (WR-L)
• Repeat blood cultures to document resolution of bacteremia should be performed in children with bacteremia caused by S. aureus, regardless of clinical status. (SR-L)

Sputum Gram Stain and Culture

• Sputum samples for culture and Gram stain should be obtained in hospitalized children who can produce sputum. (WR-L)

Urinary Antigen Detection Tests

• Urinary antigen detection tests are NOT recommended for the diagnosis of pneumococcal pneumonia in children; false-positive 
  tests are common. (SR-H)

Testing For Viral Pathogens

• Sensitive and specific tests for the rapid diagnosis of influenza virus and other respiratory viruses should be used in the evaluation of children with CAP. (SR-H)

Note: A positive influenza test may both decrease the need for additional diagnostic studies and decrease antibiotic use, while guiding appropriate use of antiviral agents in both outpatient and inpatient settings.

• Antibacterial therapy is not necessary for children, either outpatients or inpatients, with a positive test for influenza virus in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection. (SR-H)
• Testing for respiratory viruses other than influenza virus can modify clinical decision-making in children with suspected pneumonia, since antibacterial therapy will not routinely be required for these children in the absence of clinical, laboratory or radiographic findings that suggest bacterial coinfection. (WR-L)

Testing for Atypical Bacteria

• Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. (WR-M)

• Diagnostic testing for Chlamydophila pneumoniae is NOT recommended since reliable and readily available diagnostic tests do not currently exist. (SR-H)

Ancillary Diagnostic Testing

Complete Blood Count

• Routine measurement of the complete blood count is not necessary in all children with suspected CAP managed in the outpatient setting but, for those with more serious disease, may provide useful information for clinical management in the context of the clinical examination and other laboratory and imaging studies. (WR-L)
• A complete blood count should be obtained for patients with severe pneumonia, to be interpreted in the context of the clinical examination and other laboratory and imaging studies. (WR-L)

Acute-Phase Reactants

• Acute-phase reactants such as the erythrocyte sedimentation rate, C-reactive protein, or serum procalcitonin cannot be used as the sole determinant to distinguish between viral and bacterial causes of CAP. (SR-H)
• Acute phase reactants need not be routinely measured in fully-immunized children with CAP who are managed as outpatients, although for more serious disease, acute-phase reactants may provide useful information for clinical management. (SR-L)
• In patients with more serious disease such as those requiring hospitalization or those with pneumonia-associated complications, acute-phase reactants may be used in conjunction with clinical findings to assess response to therapy. (WR-L)

Pulse Oximetry

• Pulse oximetry should be performed on all children with pneumonia and suspected hypoxemia. The presence of hypoxia should guide decisions regarding site of care and further diagnostic testing. (SR-M)

Chest Radiography

Initial Chest Radiographs: Outpatient

• Routine chest radiographs are not necessary for the confirmation of suspected CAP in patients well enough to be treated in the outpatient setting (following evaluation in the office, clinic or emergency department setting). (SR-H)
• Chest radiographs, posteroanterior (PA) and lateral, should be performed in patients with suspected or documented hypoxia or significant respiratory distress (Table 2) and in patients failing initial antibiotic therapy to verify the presence or absence of complications of pneumonia, including parapneumonic effusions, necrotizing pneumonia, and pneumothorax. (SR-M)

Initial Chest Radiographs: Inpatient

• Chest radiographs (PA and lateral) should be performed in all patients hospitalized for management of CAP to document the presence, size, and character of parenchymal infiltrates and identify complications of pneumonia that may lead to interventions beyond antimicrobial agents and supportive medical therapy. (SR-M)

Follow-up Chest Radiograph

• Repeat chest radiographs are not routinely required in children who recover uneventfully from an episode of CAP. (SR-M)
• A repeat chest radiograph should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration within 48-72 hours following initiation of antibiotic therapy. (SR-M)
• Routine daily chest radiography is NOT recommended in children with pneumonia complicated by parapneumonic effusion following chest tube placement or following video-assisted thoracoscopic surgery (VATS), if they remain clinically stable. (SR-L)
• Follow-up chest radiographs should be obtained in patients with complicated pneumonia with worsening respiratory distress or clinical instability, or in those with persistent fever that is not responding to therapy over 48-72 hours. (SR-L)
• Repeat chest radiographs 4-6 weeks after the diagnosis of CAP should be obtained in patients with recurrent pneumonia involving the same lobe and in patients with lobar collapse on initial chest radiography with suspicion of an anatomic anomaly, chest mass or foreign body aspiration. (SR-M)

Severe of Life-Threatening CAP

• The clinician should obtain tracheal aspirates for Gram stain and culture, as well as clinically- and epidemiologically-guided testing for viral pathogens, including influenza virus, at the time of initial endotracheal tube placement in children requiring mechanical ventilation. (SR-L)
• Bronchoscopic or blind protected specimen brush sampling, bronchoalveolar lavage (BAL), percutaneous lung aspiration, or open lung biopsy should be reserved for the immunocompetent child with severe CAP if initial diagnostic tests are not positive. (WR-L)

Table 1. Complications Associated with CAP

• Pulmonary
• Pleural effusion/empyema
• Pneumothorax
• Lung abscess
• Bronchopleural fistula
• Necrotizing pneumonia
• Acute respiratory failure
• Metastatic
• Meningitis
• Central nervous system abscess
• Pericarditis
• Endocarditis
• Osteomyelitis
• Septic arthritis
• Systemic
• Systemic inflammatory response syndrome/sepsis
• Hemolytic uremic syndrome

Table 2. Criteria for Respiratory Distress

Signs of Respiratory Distress in Children with Pneumonia

• Tachypnea, respiratory rate, breaths/min^a

• 3-12 mo: > 50

• 1-5 y: > 40

• > 5 y: > 20

• Dyspnea

• Retractions (suprasternal, intercostals or subcostal)

• Grunting

• Nasal flaring

• Apnea

• Altered mental status

• Pulse oximetry < 90% on room air

^a Adapted from World Health Organization (WHO) criteria.

Table 3. Criteria for CAP Severity of Illness^a

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Clinician should consider care in an ICU or a unit with continuous cardiorespiratory monitoring for the child having ≥ 1 major, or ≥ 2 minor, criteria

• Major criteria:
  • Invasive mechanical ventilation
  • Fluid refractory shock
  • Acute need for NIPPVb
  • Hypoxia requiring FiO2 greater than inspired concentration or flow feasible in general care area

• Minor criteria:
  • Respiratory rate > WHO classification for age
  • Apnea
  • Increased work of breathing (eg, retractions, dyspnea, nasal flaring, grunting)
  • PaO2/FiO2 < 250
  • Multilobar infiltrates
  • PEWS score > 6
  • Altered mental status
  • Hypotension
  • Presence of effusion
  • Comorbid conditions (eg, HgbSS, immunosuppression, immunodeficiency)
  • Unexplained metabolic acidosis

^a Modified from Table 4 in Mandell et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S38. Abbreviations: FiO2, fraction of inspired oxygen; HgbSS, Hemoglobin SS disease; NIPPV, noninvasive positive pressure ventilation; PaO2, arterial oxygen pressure; PEWS, Pediatric Early Warning Score