Blood and sputum cultures not always indicated. The IDSA/PIDS guidelines strongly recommend obtaining blood cultures for hospitalized patients with moderate-to-severe pneumonia, particularly those with complications.1
The guidelines strongly recommend against blood cultures for fully immunized children with CAP who are treated as outpatients. However, blood cultures are strongly recommended for any child who fails to improve after initiation of antibiotic therapy.1 These recommendations are consistent with clinical data, expert opinion, and other treatment guidelines.1,8,13-18
A weak recommendation from the new guidelines states that if a hospitalized child with CAP can produce sputum, gram staining of the specimen may be warranted.1,8,13,15
Use pulse oximetry. The guidelines strongly recommend using pulse oximetry with all children who have pneumonia or suspected hypoxemia.1,18
When chest radiography can help. Routine chest radiography may not be warranted for suspected CAP treated in the outpatient setting. Order chest films for patients with suspected or confirmed hypoxemia or respiratory distress (who tend to have worse outcomes), and for patients who do not respond to initial antibiotic treatment.1,18 Follow-up radiographs are recommended for patients with advancing symptoms 2 to 3 days after starting antibiotics, complicated pneumonia with worsening respiratory distress, or clinical symptoms without improvement.1
Other diagnostic tests mentioned in the guidelines include complete blood cell counts, which are recommended in severe cases of pneumonia.1
Acute-phase reactants such as erythrocyte sedimentation rate (ESR), serum procalcitonin, and C-reactive protein concentrations cannot distinguish between viral and bacterial causes of CAP, and are not routinely recommended for patients treated in the outpatient setting.1,13
For patients requiring endotracheal intubation, gram staining and cultures of aspirates of the trachea and virus testing are recommended.1
Immunocompetent patients hospitalized with severe CAP may be candidates for percutaneous lung aspiration, open lung biopsy, bronchoalveolar lavage (BAL), or bronchoscopic or blind protected brush specimen collection if prior diagnostic tests are negative.1
CAP treatment and prevention
The guidelines provide recommendations for treating bacterial and viral CAP in either inpatient or outpatient settings, and discuss appropriate preventive techniques.
Antiviral therapy. As mentioned earlier, children less than 2 years of age are commonly infected with viral pathogens. Those with mild cases of viral CAP do not require anti-microbial therapy. For children with moderate-to-severe CAP consistent with influenza infection, administer influenza antiviral therapy as soon as possible, especially during a widespread local circulation of influenza viruses. Some influenza A strains will be susceptible to antiviral therapy, even though genetic variability is high each year. The guidelines’ recommended agents for treating influenza in pediatric patients are listed in TABLE 1.1
TABLE 1
Influenza antiviral therapy in pediatric patients*1
| Drug (brand name) | Formulation | Dosing |
|---|---|---|
| Oseltamivir (Tamiflu) | 75 mg capsule; 60 mg/5 mL suspension | 4-8 mo: 6 mg/kg/d in 2 doses 9-23 mo: 7 mg/kg/d in 2 doses ≥24 mo: ~4 mg/kg/d in 2 doses, for 5 days ≤15 kg: 60 mg/d in 2 divided doses >15-23 kg: 90 mg/d in 2 divided doses >23-40 kg: 120 mg/d in 2 divided doses >40 kg: 150 mg/d in 2 divided doses |
| Zanamivir (Relenza) | 5 mg per inhalation, using a Diskhaler | ≥7 y: 2 inhalations (10 mg total per dose), twice daily for 5 days |
| Amantadine (Symmetrel)† | 100 mg tablet; 50 mg/5 mL suspension | 1-9 y: 5-8 mg/kg/d as single daily dose or in 2 doses; not to exceed 150 mg/d 9-12 y: 200 mg/d in 2 doses (not studied as a single dose) |
| Rimantadine (Flumadine)† | 100 mg tablet; 50 mg/5 mL suspension | Not FDA approved for treatment in children, but published data exist on safety and efficacy in children Suspension: 1-9 y: 6.6 mg/kg/d (max 150 mg/kg/d) in 2 doses ≥10 y: 200 mg/d, as single daily dose or in 2 doses |
| *In children for whom prophylaxis is indicated, antiviral drugs should be continued for the duration of known influenza activity in the community (because of the potential for repeated exposures) or until immunity can be achieved as a result of immunization. †Amantadine and rimantadine should be used for treatment and prophylaxis only in the winter, when most isolated influenza A virus strains are susceptible to adamantine; the adamantines should not be used for primary therapy because of the rapid emergence of resistance. However, for patients requiring adamantine therapy, a treatment course of about 7 days is suggested, or one that runs until a day or 2 after the signs and symptoms have disappeared. | ||
Antibacterial therapy. For patients with a suspected bacterial pathogen, start empiric antibiotic therapy as soon as possible. Preferred and alternative agents for specific age groups, immunization status, and specific pathogen(s) appear in TABLE 2.1,19