Community-Acquired Pneumonia in Children. What’s New 2011
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GUIDELINE UPDATE Community-acquired pneumonia in children: what’s new? Anne Thomson, Michael Harris ABSTRACT The community-acquired pneumonia in children guidelines have just been updated with new evidence on incidence, aetiology and management. This guidance should improve patient care. The British Thoracic Society (BTS) guidelines have recently been updated, reflecting 10 years of new evidence. 1 What have we learned in that time? The past decade has brought new diagnostic techniques, the introduction of universal infant pneumococcal vaccination and new information on antibiotic delivery. Community-acquired pneumonia (CAP) is common and most is seen and treated in the community. The guideline confirms that no diag- nostic tests are necessary in the community but emphasises the importance of providing families with information, including advice on manage- ment, identifying any deterioration and the importance of reassessment. The incidence of children admitted to hospital with CAP (defined as fever, clinical signs and chest radiograph infiltrate) in the prepneumococcal vaccine era was 33/10 000 aged 0e5 years and 14.5/ 10 000 aged 0e16 years evidenced from remarkably consistent prospective studies in Norway and the UK. 23 Infant vaccination with PCV 7 (seven-valent pneumococcal conjugate vaccination) started in the UK in 2007, and a national time trends study has shown a 19% decrease in admission rates between 2006 and 2008. 4 In countries such as the USA where PCV 7 has been available for longer, a decrease in hospital admissions of w30% is reported. When establishing aetiology, new PCR tech- niques have improved diagnostic yield so that a pathogen can be detected in 65e86% of cases. This careful work has identified mixed viralebacterial infection in 23e33% of CAP cases. Streptococcus pneumoniae remains by far the most common bacterial cause and is found in 30e40% of cases as a single or co-pathogen. Group A Strepto- coccus contributes 1e7% of cases. Mycoplasma and Chlamydia pneumoniae are found with variable frequency and are not uncommon in the preschool child. The common winter viruses respiratory syncytial virus (RSV), parainfluenza and influenza are frequent pathogens, but the newer identified viruses such as human metapneumovirus and human bocavirus are found in 8e12% and w5%, respectively. Overall viruses account for 30e67% of cases and are most frequent in children <1 year of age. 5 6 In the 2002 guidance, clinicians were encouraged to search for a pathogen in all cases, but this has been revised to more practical guidance that aetiological investigation be restricted to those with either severe or complicated disease. Clinical features of pneumonia are not specific for aetiology, and the evidence is that chest radio- graph findings do not help in this respect. The WHO produced a method for standardising the interpretation of chest radiographs in children, but, even using this, the concordance rate between trained reviewers was only 48%. 7 Little wonder that chest radiograph interpretation can create heated discussions on ward rounds! Investigation of the use of acute phase reactants as a means of differentiating aetiology and/or severity of CAP has continued over the past 10 years. There have been many publications and much heat, but no light. The outcome is simply to reinforce the guidance that they are not of clinical utility in distinguishing viral from bacterial infections and should not be a routine test. Oxygen saturation <92% is an indicator of severity and the need for oxygen therapy. No new studies on oxygen delivery were identified. Simi- larly, there were no new studies on physiotherapy, but good quality evidence already exists that it is not beneficial and should not be performed in chil- dren with pneumonia. The BTS paediatric pneu- monia audit data from 2010 showed that 15% (of 2209 cases reported) were nevertheless receiving it. So how does this evidence help us decide who should receive antibiotics? We know that viruses are the most common cause of lower respiratory tract infection (LRTI) in young children. In a vaccine probe study, only 6% of children <2 years old with a clinical diagnosis of pneumonia had Pneumococcus identified. 8 With the introduction of PCV 13 the likelihood of bacterial pneumonia in a fully vaccinated child will fall further. Fully vaccinated children <2 years old presenting with mild symptoms of LRTI need not be treated with antibiotics, but should be reviewed if symptoms persist. The evidence is that bacterial and viral pneumonia cannot reliably be distinguished and therefore all other children with a clear clinical diagnosis of pneumonia should receive antibiotics. Which antibiotic should be used? On the basis of the known common bacterial pathogens in children and available randomised controlled trials of different antibiotics, amoxicillin is effective, well tolerated and cheap. In the past some paediatricians have been anxious that Mycoplasma pneumoniae be covered, and have in addition used macrolide Oxford Children’s Hospital, The John Radcliffe, Headington, Oxford, UK Correspondence to Dr Anne Thomson, Oxford Children’s Hospital, The John Radcliffe, Headley Way, Headington, Oxford OX3 9DU, UK; [email protected] Received 23 June 2011 Accepted 24 June 2011 Thorax 2011;66:927e928. doi:10.1136/thoraxjnl-2011-200671 927 Chest clinic group.bmj.com on April 27, 2014 - Published by thorax.bmj.com Downloaded from
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Community-Acquired Pneumonia in Children. What’s New 2011
Transcript of Community-Acquired Pneumonia in Children. What’s New 2011
GUIDELINE UPDATE
Community-acquired pneumonia in children:what’s new?
Anne Thomson, Michael Harris
ABSTRACTThe community-acquired pneumonia in childrenguidelines have just been updated with new evidence onincidence, aetiology and management. This guidanceshould improve patient care.
The British Thoracic Society (BTS) guidelines haverecently been updated, reflecting 10 years of newevidence.1 What have we learned in that time? Thepast decade has brought new diagnostic techniques,the introduction of universal infant pneumococcalvaccination and new information on antibioticdelivery.Community-acquired pneumonia (CAP) is
common and most is seen and treated in thecommunity. The guideline confirms that no diag-nostic tests are necessary in the community butemphasises the importance of providing familieswith information, including advice on manage-ment, identifying any deterioration and theimportance of reassessment.The incidence of children admitted to hospital
with CAP (defined as fever, clinical signs and chestradiograph infiltrate) in the prepneumococcalvaccine era was 33/10 000 aged 0e5 years and 14.5/10 000 aged 0e16 years evidenced from remarkablyconsistent prospective studies in Norway and theUK.2 3 Infant vaccination with PCV 7 (seven-valentpneumococcal conjugate vaccination) started in theUK in 2007, and a national time trends study hasshown a 19% decrease in admission rates between2006 and 2008.4 In countries such as the USAwhere PCV 7 has been available for longer, adecrease in hospital admissions ofw30% is reported.When establishing aetiology, new PCR tech-
niques have improved diagnostic yield so thata pathogen can be detected in 65e86% of cases.This careful work has identified mixedviralebacterial infection in 23e33% of CAP cases.Streptococcus pneumoniae remains by far the mostcommon bacterial cause and is found in 30e40% ofcases as a single or co-pathogen. Group A Strepto-coccus contributes 1e7% of cases. Mycoplasma andChlamydia pneumoniae are found with variablefrequency and are not uncommon in the preschoolchild. The common winter viruses respiratorysyncytial virus (RSV), parainfluenza and influenzaare frequent pathogens, but the newer identifiedviruses such as human metapneumovirus andhuman bocavirus are found in 8e12% and w5%,respectively. Overall viruses account for 30e67% ofcases and are most frequent in children <1 year of
age.5 6 In the 2002 guidance, clinicians wereencouraged to search for a pathogen in all cases, butthis has been revised to more practical guidancethat aetiological investigation be restricted to thosewith either severe or complicated disease.Clinical features of pneumonia are not specific
for aetiology, and the evidence is that chest radio-graph findings do not help in this respect. TheWHO produced a method for standardising theinterpretation of chest radiographs in children, but,even using this, the concordance rate betweentrained reviewers was only 48%.7 Little wonderthat chest radiograph interpretation can createheated discussions on ward rounds! Investigationof the use of acute phase reactants as a means ofdifferentiating aetiology and/or severity of CAP hascontinued over the past 10 years. There have beenmany publications and much heat, but no light.The outcome is simply to reinforce the guidancethat they are not of clinical utility in distinguishingviral from bacterial infections and should not bea routine test.Oxygen saturation <92% is an indicator of
severity and the need for oxygen therapy. No newstudies on oxygen delivery were identified. Simi-larly, there were no new studies on physiotherapy,but good quality evidence already exists that it isnot beneficial and should not be performed in chil-dren with pneumonia. The BTS paediatric pneu-monia audit data from 2010 showed that 15% (of2209 cases reported) were nevertheless receiving it.So how does this evidence help us decide who
should receive antibiotics? We know that virusesare the most common cause of lower respiratorytract infection (LRTI) in young children. Ina vaccine probe study, only 6% of children <2 yearsold with a clinical diagnosis of pneumonia hadPneumococcus identified.8 With the introduction ofPCV 13 the likelihood of bacterial pneumonia ina fully vaccinated child will fall further. Fullyvaccinated children <2 years old presenting withmild symptoms of LRTI need not be treated withantibiotics, but should be reviewed if symptomspersist. The evidence is that bacterial and viralpneumonia cannot reliably be distinguished andtherefore all other children with a clear clinicaldiagnosis of pneumonia should receive antibiotics.Which antibiotic should be used? On the basis of
the known common bacterial pathogens in childrenand available randomised controlled trials ofdifferent antibiotics, amoxicillin is effective, welltolerated and cheap. In the past some paediatricianshave been anxious that Mycoplasma pneumoniae becovered, and have in addition used macrolide
Oxford Children’s Hospital, TheJohn Radcliffe, Headington,Oxford, UK
Correspondence toDr Anne Thomson, OxfordChildren’s Hospital, The JohnRadcliffe, Headley Way,Headington, Oxford OX3 9DU,UK; [email protected]
Received 23 June 2011Accepted 24 June 2011
Thorax 2011;66:927e928. doi:10.1136/thoraxjnl-2011-200671 927
Chest clinic
group.bmj.com on April 27, 2014 - Published by thorax.bmj.comDownloaded from
antibiotics. However, a Cochrane review did not find enoughevidence to indicate that antibiotics improved outcomes inchildren with M pneumoniae LRTI.9 Studies using only amoxi-cillin have had very low failure rates. Macrolide antibioticsshould not be first line but can be added at any age if there is noresponse to first-line empirical therapy.
There is important new evidence on how those antibioticsshould be given. The PIVOT trial randomised UK children overthe age of 6 months to either oral amoxicillin or intravenouspenicillin, and the outcomes were equivalent (with a shorterduration of hospital stay in the oral group).10 Similar resultshave been reported in the developing world. Oral amoxicillin istherefore the antibiotic of choice both in the community and inhospital. Intravenous antibiotics should be reserved for childrenunable to absorb oral drugs or those presenting with septicaemiaor complicated pneumonia.
These recommendations should result in significant changesto practice and be welcomed in these financially challengedtimes as they should decrease costs with no change in effec-tiveness of treatment. Junior doctors are creatures of habit andfeel (rightly or wrongly) that they are more likely to be criticisedfor underinvestigation than overinvestigation and usually sendlaboratory tests when inserting an intravenous line. Now: nointravenous line, no tests, no physiotherapy. Simple oral anti-biotics and supportive care will be effective for the majority ofchildren with CAP, who will also escape from hospital faster.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
REFERENCES1. Harris M, Clark J, Coote N, et al. BTS guidelines for the management of community
acquired pneumonia in children: update 2011. Thorax 2011. doi:10.1136/thoraxjnl-2011-200598
2. Senstad AC, Suren P, Brauteset L, et al. Community-acquired pneumonia (CAP) inchildren in Oslo, Norway. Acta Paediatr 2009;98:332e6.
3. Clark JE, Hammal D, Hampton F, et al. Epidemiology of community-acquiredpneumonia in children seen in hospital. Epidemiol Infect 2007;135:262e9.
4. Koshy E, Murray J, Bottle A, et al. Impact of the seven-valent pneumococcalconjugate vaccination (PCV7) programme on childhood hospital admissions forbacterial pneumonia and empyema in England: national time-trends study,1997e2008. Thorax 2010;65:770e4.
5. Michelow IC, Olsen K, Lozano J, et al. Epidemiology and clinical characteristics ofcommunity-acquired pneumonia in hospitalized children. Pediatrics 2004;113:701e7.
6. Cevey-Macherel M, Galetto-Lacour A, Gervaix A, et al. Etiology of community-acquired pneumonia in hospitalised children based on WHO clinical guidelines. Eur JPediatr 2009;168:1429e36.
7. WHO. WHO Model Chapter for Textbooks: IMCI, Integrated Management ofChildhood Illness. Geneva: WHO, 2001.
8. Lucero MG, Dulalia VE, Parreno RN, et al. Pneumococcal conjugate vaccines forpreventing vaccine-type invasive pneumococcal disease and pneumonia withconsolidation on x-ray in children under two years of age. Cochrane Database SystRev 2004;(4):CD004977.
9. Mulholland S, Gavranich JB, Chang AB. Antibiotics for community-acquired lowerrespiratory tract infections secondary to Mycoplasma pneumoniae in children.Cochrane Database Syst Rev 2010;(7):CD004875.
10. Atkinson M, Lakhanpaul M, Smyth A, et al. A multicentre randomised controlledequivalence trial comparing oral amoxicillin and intravenous benzyl penicillin forcommunity acquired pneumonia in children PIVOT Trial. Thorax 2007;62(12):1102e6
928 Thorax 2011;66:927e928. doi:10.1136/thoraxjnl-2011-200671
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doi: 10.1136/thoraxjnl-2011-200671 2011 66: 927-928Thorax
Anne Thomson and Michael Harris children: what's new?Community-acquired pneumonia in
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