Paediatric Pathways

Community acquired pneumonia (cap) and empyema pathway for children presenting to hospital

DIAGNOSIS

Clinical features consistent with CAP include
Cough, fever, breathlessness, tachypnoea, chest recession, crackles /wheeze on auscultation.
Consider differentials*
This pathway should not be applied to children unlikely to have CAP. Presence of generalised wheeze makes viral aetiology far more likely and presence of fever is an essential feature in CAP.

*DIFFERENTIALS:

  • Bronchiolitis
  • Viral induced wheeze
  • Acute exacerbation of asthma
  • Croup
  • Inhaled foreign body
  • Pertussis
  • Pneumothorax
  • Metabolic acidosis e.g. DKA
  • Heart Failure

ASSESSING SEVERITY

Decision making about antimicrobial therapy, investigation and need for admission is influenced by severity of illness.
#Features of severe disease include:

  • Significant tachypnoea*
  • Significant tachycardia*
  • Severe respiratory distress (significant recession (age <12 months), nasal flaring, grunting)
  • Apnoeas (ages <12 months)
  • Hypoxia (sustained O2 sats ≤92% in room air)
  • Cyanosis
  • Signs of severe dehydration
  • Capillary Refill Time >2 secs

If features of sepsis, for urgent senior input / paediatric input

*Parameters for significant tachycardia / tachypnoea:
Age <6 months: RR>70, HR>170 Age 6-12 months: RR>70, HR>170 Age 1 year to < 3 years: RR>50, HR>150 Age 3 year to 5 years: RR>50, HR>140 Age 5 year to 14 years: RR>40, HR>120 Age 14 years to 17 years: RR>30, HR>100

INVESTIGATIONS

If no features of severe disease, no investigations routinely indicated.

If features of SEVERE respiratory distress:

  • FBC, U&E, creatinine, CRP & blood culture
  • Consider respiratory viral testing if diagnosis of bronchiolitis considered
  • Consider other appropriate microbiological investigations
  • Consider performing a CXR (AP film), especially if hypoxia or significant respiratory distress. Also consider if no improvement in symptoms despite >48 hours of adequate oral Ab therapy.

 

MANAGEMENT

MILD SEVERITY: child < 5 years with absence of persistent/recurrent fever over preceding 24-48 hours, no respiratory distress and no tachypnoea.

No antibiotics required
Provide verbal and written safety netting information (under 12 months, >12 months)

MANAGEMENT

MODERATE SEVERITY: persistent/recurrent fever over preceding 24-48 hours, respiratory distress and/or tachypnoea.

If likely diagnosis of CAP, manage with oral antibiotics as per local or national guidelines.1-7 Total Abx course = 5 days.1,3
Provide verbal and written safety netting information (under 12 months, >12 months)

Consider IVAbx if:

  • Oral Abx not tolerated/absorbed
  • No improvement despite ≥48 hours of adequate oral Abx therapy (check dose and adherence)
  • Significant immunosuppression, chronic lung or heart disease

Consider ambulation13 on IVAbx unless:

Ensure robust clinical governance systems in place for children being ambulated and appropriate documentation. Daily review required. IV to oral switch when clinically improving +- improving inflammatory markers. Choice of oral antibiotics as per local or national guidelines. Total Abx course (IV+oral)=5 days1,3

If no improvement despite 48 hours Abx, consider complicated pneumonia# or alternative non-infective diagnosis.

MANAGEMENT

SEVERE disease # and/or presence of empyema

Observe in hospital and start antibiotics as per local or national guidelines.

  • consider IV Abx if unable to tolerate orals or complicated pneumonia (empyema/necrotising pneumonia) or significantly immunosuppression

During periods when influenza is known to be circulating locally, consider empirical antiviral therapy in children with risk factors for severe influenza whilst awaiting respiratory virus results (in children requiring PICU/PHDU support, consider empirical antiviral treatment even in children without risk factors whilst awaiting respiratory virus results).
Perform X-Ray and proceed to a chest ultrasound scan if radiological or clinical evidence of effusion. Consider possible complicated pneumonia (including empyema and necrotising pneumonia) if no significant response to antibiotic therapy after 48 hours.
If empyema present, initially manage conservatively unless significant respiratory compromise or evidence of toxic shock syndrome. If no clinical improvement within 48 hours of IVAbx, repeat USS and consider drainage.
IV to oral switch when clinically improving +/- improving inflammatory markers +/- removal of chest drain (see BTS guidelines https://thorax.bmj.com/content/60/suppl_1/i1).10, 12
Choice of oral antibiotics as per local or national guidelines. Total duration of Abs 5 days (unless complicated pneumonia ie. empyema or necrotising pneumonia – minimum 14 days Abx course / 4 weeks if loculated empyema).8,11 Provide verbal and written safety netting information on discharge (under 12 months, >12 months)

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. NICE (National Institute for Health and Care Excellence). Pneumonia (community-acquired): antimicrobial prescribing. NICE guideline: [NG138]. Available at https://www.nice.org.uk/guidance/ng138. 2019.
  2. Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database Syst Rev 2008; 10.1002/14651858.CD005976.pub2: CD005976.
  3. Greenberg D, Givon-Lavi N, Sadaka Y et al. 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.
  4. Atkinson M, Lakhanpaul M, Smyth A et al. Comparison of oral amoxicillin and intravenous benzyl penicillin for community acquired pneumonia in children (PIVOT trial): a multicentre pragmatic randomised controlled equivalence trial. Thorax 2007; 62: 1102-6.
  5. Addo-Yobo E, Chisaka N, Hassan M et al. Oral amoxicillin versus injectable penicillin for severe pneumonia in children aged 3 to 59 months: a randomised multicentre equivalency study. Lancet 2004; 364: 1141-8.
  6. Hazir T, Fox LM, Nisar YB et al. Ambulatory short-course high-dose oral amoxicillin for treatment of severe pneumonia in children: a randomised equivalency trial. Lancet 2008; 371: 49-56.
  7. Lodha R, Kabra SK, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database Syst Rev 2013; 10.1002/14651858.CD004874.pub4: CD004874.
  8. Kushner LE, Nieves DJ, Osborne S et al. Oral Antibiotics for Treating Children With Community-Acquired Pneumonia Complicated by Empyema. Clin Pediatr 2019; http://dx.doi.org/10.1177/0009922819850494.
  9. Shah SS, Srivastava R, Wu S et al. Intravenous Versus Oral Antibiotics for Postdischarge Treatment of Complicated Pneumonia. Pediatrics 2016; 138.
  10. Balfour-Lynn IM, Abrahamson E, Cohen G et al. BTS guidelines for the management of pleural infection in children. Thorax 2005; 60 Suppl 1: i1-21.
  11. Stockmann C, Ampofo K, Pavia AT et al. Comparative Effectiveness of Oral Versus Outpatient Parenteral Antibiotic Therapy for Empyema. Hosp Pediatr 2015; 5: 605-12.
  12. Segerer FJ, Seeger K, Maier A et al. Therapy of 645 children with parapneumonic effusion and empyema-A German nationwide surveillance study. Pediatr Pulmonol 2017; 52: 540-7.
  13. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.