British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Authors Michael Harris Paediatric Registrar, Oxford Children‘s Hospital, The John Radcliffe, Headley Way, Headington, Oxford, OX3 9DU Julia Clark Consultant Paediatric Immunology and Infectious Disease, Department of Paediatric Immunology and Infectious Diseases, Old COPD, Great North Children‘s Hospital, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP Nicky Coote Consultant Paediatrician, Children's Ambulatory Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0HS Penny Fletcher Senior Lead Pharmacist Women and Children, (St Mary's Hospital), Pharmacy Department, Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed Street, London, W2 1NY Anthony Harnden University Lecturer and Principal in General Practice, Department of Primary Health Care, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF Michael McKean Consultant Respiratory Paediatrician, Department of Paediatric Respiratory Medicine, 3rd Floor Doctor's Residency Building, Royal Victoria Infirmary, Newcastle-upon-Tyne, NE61 1JR Anne Thomson Consultant Respiratory Paediatrician, Oxford Children‘s Hospital, The John Radcliffe, Headley Way, Headington, Oxford, OX3 9DU Email:[email protected] Tel:01865234194 BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 Synopsis of Recommendations Clinical Features Bacterial pneumonia should be considered in children when there is persistent or repetitive fever >38.5oC together with chest recession and a raised respiratory rate. [D] Investigations Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia (CAP). [A-] Children with signs and symptoms of pneumonia who are not admitted to hospital should not have a chest radiograph. [A-] A lateral radiograph should not be performed routinely. [B-] Acute phase reactants are not of clinical utility in distinguishing viral from bacterial infections and should not routinely be tested. [A-] CRP is not useful in the management of uncomplicated pneumonia and should not be measured routinely. [A+] Microbiological diagnosis should be attempted in children with severe pneumonia, sufficient to require paediatric intensive care admission, or those with complications of CAP. [C] Microbiological investigations should not be considered routinely in those with milder disease or those treated in the community. [C] Microbiological methods used should include: o Blood culture. [C] o Nasopharyngeal secretions and/or nasal swabs for viral detection by PCR and/or immunofluorescence. [C] o Acute and convalescent serology for respiratory viruses, Mycoplasma and Chlamydia. [B+] o If present, pleural fluid should be sent for microscopy, culture, pneumococcal antigen detection and/or PCR. [C] o Urinary pneumococcal antigen detection should not be done in young children. [C] Severity Assessment For a child in the community, re-consultation to the general practitioner with persistent fever, or parental concern about persistent fever, should prompt consideration of CAP. [D] For children with CAP, reassessment is important, whether in the community or in hospital. [D] Hypoxia (SaO2 <92%) in all children is an indication for hospital assessment and management. [B+] Auscultation revealing absent breath sounds with a dull percussion note should raise the possibility of a pneumonia complicated by effusion and should trigger a referral to hospital. [B-] A child in hospital should be reassessed medically if there is persistence of fever 48 hours after initiation of treatment, increased work of breathing or if the child is becoming distressed or agitated. [D] BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 General Management Families of children who are well enough to be cared for at home should be given information on managing pyrexia, preventing dehydration, and identifying any deterioration. [D] Patients whose oxygen saturation is 92% or less while breathing air should be treated with oxygen given by nasal cannulae, high flow delivery device, head box or face mask to maintain oxygen saturation above 92%. [B] Nasogastric tubes may compromise breathing and should therefore be avoided in severely ill children and especially in infants with small nasal passages. If use cannot be avoided, the smallest tube should be passed down the smallest nostril. [D] Plasma sodium, potassium, urea and/or creatinine should be measured at baseline and at least daily when on intravenous fluids. [C] Chest physiotherapy is not beneficial and should not be performed in children with pneumonia. [A-] Antibiotic Management Children under 2 years, presenting with mild symptoms of lower respiratory tract infection need not be treated with antibiotics but should be reviewed if symptoms persist. A history of conjugate pneumococcal vaccination gives greater confidence to this decision. [C] As bacterial pneumonia cannot be clinically distinguished from viral, all other children with a clinical diagnosis of pneumonia should receive antibiotics. [C] Amoxicillin is first choice for oral antibiotic therapy in all children because it is effective against the majority of pathogens which cause CAP in this group, is well tolerated, and cheap. Alternatives are co- amoxiclav, cefaclor, erythromycin, azithromycin and clarithromycin. [B] Macrolide antibiotics may be added at any age if there is no response to first line empiric therapy. [D] Macrolide antibiotics should be used if either mycoplasma or chlamydia pneumonia is suspected (or in very severe disease). [D] Amoxicillin should be used as first line treatment at any age if S. pneumoniae is thought to be the likely pathogen. [B] If Staph. aureus is thought the likely pathogen, augmentin or a combination of flucloxacillin with amoxicillin, is appropriate. [D] In pneumonia associated with influenza, co-amoxiclav is recommended. [D] Antibiotics administered orally are safe and effective for children presenting with even severe CAP and are recommended. [A+] Intravenous antibiotics should be used in the treatment of pneumonia in children when the child is unable to tolerate oral fluids or absorb oral antibiotics (for example, because of vomiting) or presents with signs of sepsis or complicated pneumonia. [D] Appropriate intravenous antibiotics for severe pneumonia include amoxicillin, co-amoxiclav, cefuroxime, and cefotaxime/ceftriaxone. These can be rationalised if a microbiological diagnosis is made. [D] BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 In a patient who is receiving intravenous antibiotic therapy for the treatment of CAP, oral treatment should be considered if there is clear evidence of improvement. [D] Children less than 2 years old, presenting with mild symptoms of lower respiratory tract infection who are unvaccinated or felt to require antibiotics, 3 days amoxicillin can be given. [B] All other children should have standard 5 day course amoxicillin in the absence of any short course evidence. [D] Complications If a child remains pyrexial or unwell 48 hours after treatment has commenced, re-evaluation is necessary with consideration given to possible complications. [D] Children with severe pneumonia, empyema and lung abscesses should be followed up after discharge until they have recovered completely and their chest radiograph has returned to near normal. [D] Follow up Follow-up radiography is not required in those who were previously healthy and who are recovering well, but should be considered in those with a round pneumonia, collapse or persisting symptoms. [B+] BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 1. Introduction and Methods The British Thoracic Society (BTS) first published management guidelines for Community Acquired Pneumonia (CAP) in children in 2002 and covered available evidence to early 2000. These updated guidelines represent a review of new evidence since then and consensus clinical opinion where evidence was not found. As before, these guidelines have been produced in parallel with those being produced for adults, which have also been updated. This document incorporates material from the 2002 guidelines and supersedes the previous guideline document. Community acquired pneumonia can be defined clinically as the presence of signs and symptoms of pneumonia in a previously healthy child due to an infection which has been acquired outside hospital. In developed countries this can be verified by the radiological finding of consolidation. In the developing world a more practical term – acute lower respiratory tract infection - is preferred, reflecting the difficulties in obtaining a radiograph. Ideally, the definition would include the isolation of a responsible organism. However, it is apparent from many studies that a pathogen is not identified in a significant proportion of cases that otherwise meet the clinical definition (see section 3 on Aetiology). As it is assumed that CAP is caused by infection, the BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 presumption is that current techniques have insufficient sensitivity to detect all relevant pathogens. Treatment guidelines therefore have to assume that, where pathogens are isolated, they represent all likely pathogens. There is a clear need for better diagnostic methods. In creating guidelines it is necessary to assess all available evidence with consideration of the quality of that evidence. This we have endeavoured to do. We have then produced a combination of evidence statements and recommendations about management based on the available evidence, supplemented by consensus clinical opinion where no relevant evidence was found. Methods of Guideline Development Scope of guidelines These guidelines address the management of CAP in infants and children in the United Kingdom. They do not include neonates or infants with respiratory syncytial virus bronchiolitis, nor children with upper respiratory tract infection, mild fever and wheeze. The specific management of children with pre-existing respiratory disease or that of opportunistic pneumonias in immunosuppressed children is not addressed. Guideline Development Group BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 The guideline development group was set up by the BTS Standards of Care Committee and comprised two paediatricians with a special interest in respiratory disease, a paediatrician with a special interest in paediatric infectious diseases, a general paediatrician with a special interest in ambulatory paediatrics, a specialist trainee in paediatrics, a general practitioner with an interest in childhood infection and a paediatric pharmacist. An Information Specialist developed the search strategy and ran the searches. No external funding was obtained to support the development of the guidelines. Identification of evidence A search strategy was developed by an Information Specialist from the Centre for Reviews and Dissemination in York (part of the National Institute for Health Research). The Search strategy and the results are located in Appendix 1. The Cochrane Library (DARE and Cochrane Database of Systematic Reviews), MEDLINE and EMBASE were searched from 2000 onwards. There were some technical changes made to the original search strategies to reduce the chances of missing studies: a single search strategy was used, rather than separate strategies for each subject. Studies were limited to English language in view of the limitations on time and resources. 2076 studies were identified by the searches, which were rerun in July 2010. The updated search identified a further 511 titles. BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 Assessing the literature Initial review of the 2076 titles and abstracts was undertaken by one reviewer, screening for relevance. This was repeated after the second search by another reviewer. The relevant titles and abstracts were grouped by subject matter with many papers being relevant for more than one subject area. Two reviewers then assessed the studies for inclusion. Studies from countries where the populations or clinical practices were very different from the UK were excluded unless they addressed questions that could be generalised to the UK (such as clinical assessment). Any differences of opinion were settled by a third party. The studies were appraised using the Cochrane data extraction template (Appendix 2). Any guideline statements made were graded using the same table used by the group developing the adult guidelines (Table in Appendix 3). BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 2. Incidence and economic consequences 2.1 How common is CAP in children in the community and in hospital? Two recent European papers give incidence rates for CAP in children seen in hospital (Table 2.1) which are lower than those reported previously from the 1980‘s in Finland (1) [1b]. A prospective population based study of 278 Norwegian children <16 years seen in hospital with pneumonia (temperature, clinical signs and chest radiograph infiltrate in previously well child) from 2003-2005 in Oslo gave population incidence rates per 10,000 of 14.7 aged 0-16 years, 32.8 aged 0-5 years and 42.1 aged 0-2 years (2) [III]. UK data for children seen at hospital with pneumonia (clinical findings and chest radiograph) 2001-2002 (n = 750) from a prospective population based study in 13 hospitals in the North of England are remarkably similar. Overall 14.4 aged 0-16 years per annum and 33.8 for those <5 years (per 10,000). Rates of those admitted to hospital were less at 12.2 (11.3-13.2) aged 0-16 years and 28.7 (26.2 – 31.4) aged 0-5 years (3) [II]. Table 2.1 Incidence per 10,000 population CI = confidence interval Country Disease Definition of Age CI Age CI Age CI Age CI Age CI pneumonia 0-1yr 0- 0- 0- 0- 2yrs 3yrs 5yrs 16yrs BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011 Whole Population Data Norway Pneumonia Signs & CXR 42.1 (32- 32.8 (26.8- 14.7 (12.2- 52.3) 38.8) 17.1) UK Pneumonia Signs & 33.8 (31.1- 14.4 (13.4- CXR 36.7) 15.4) Germany Pneumonia Clinical 137 (PRI.DE) including Comorbidity Germany Pneumonia Clinical by 150.1 (Schleswig- Parental 181.1 Holstein) Interview Admitted to hospital UK Pneumonia Signs & 28.7 (26.2- 12.2 (11.3- CXR 31.4) 13.2) Germany Pneumonia Signs & CXR 65.8 30 (KIEL) & including 111.3 Bronchiolitis Comorbidity Germany Pneumonia Clinical 107 (PRI.DE) including Comorbidity U.S. All cause Coding 129.6 Pneumonia Including Co morbidity A population based study in Kiel, Germany from 1996-2000 of children (n = 514) with severe i.e. hospitalised pneumonia (clinical assessment plus chest radiograph in 96.1%) included children with comorbidities. (22.8%) and almost certainly what in the UK would be called bronchiolitis (4) [II]. Here the overall incidence (per 10,000) was 30 aged 0-16 years, 65.8 aged 0-5 years and 111.3 aged 0-1 year. A series of retrospective population based cohort studies from the same Schleswig-Holstein area of Germany conducted in BTS Guidelines for the Management of Community Acquired Pneumonia in Children: Update 2011 Consultation draft: 18 January 2011