CLINICAL PRACTICE

GUIDELINES ON:

PNEUMONIA
 REFERENCES
Clinical
Practice
Guidelines
Management
and Prevention
of Adult
Community
Acquired
Pneumonia

2020 Update
CLINICAL QUESTION #1
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT
CLINICAL SIGNS AND SYMPTOMS WILL ACCURATELY DIAGNOSE COMMUNITY-
ACQUIRED PNEUMONIA?

Pediatric community-acquired pneumonia (PCAP) is considered in a patient who presents

with cough or fever, PLUS any of the following positive predictors of radiographically-
confirmed pneumonia1: (Conditional recommendation, very low-grade evidence)
1. Tachypnea
1.1 3 months to 12 months old: ≥50 breaths per minute
1.2 >1 year old to 5 years old: ≥40 breaths per minute
1.3 >5 years to 12 years old: ≥30 breaths per minute
1.4 >12 years old: ≥20 breaths per minute
2. Retractions or chest indrawing
3. Nasal flaring
4. O2 saturation <95% at room air4
5. Grunting
CLINICAL QUESTION #2
AMONG INFANTS AND CHILDREN 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT CLINICAL
AND ANCILLARY PARAMETERS WILL DETERMINE THE NEED FOR ADMISSION?

The presence of one (1) parameter, clinical and/or

imaging, in the Severe or High Risk for Mortality
category is an indication for admission.
CLINICAL QUESTION #2
AMONG INFANTS AND CHILDREN 3 MONTHS TO 18 YEARS WITH COMMUNITY-ACQUIRED PNEUMONIA, WHAT CLINICAL
AND ANCILLARY PARAMETERS WILL DETERMINE THE NEED FOR ADMISSION?

- Non-severe PCAP: outpatient basis, with recommended management plan

(advise to return to hospital if no clinical improvement OR
with signs of deterioration such as hypoxemia, chest indrawing/
retractions, grunting, altered sensorium, pallor within 48 hours)

OR:
- if the patient refuses or is unable to drink, drinks medications
- absence of caregiver
- inability for close follow-up
- no easily accessible medical facility
CLINICAL QUESTION #3
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT
DIAGNOSTIC AIDS WILL CONFIRM THE PRESENCE OF NON-SEVERE
COMMUNITY-ACQUIRED PNEUMONIA IN AN AMBULATORY SETTING?

• Routine diagnostic aids are not considered for non-severe PCAP in

an ambulatory setting. (Conditional recommendation, Expert opinion)
CLINICAL QUESTION #4
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT
DIAGNOSTIC AIDS WILL CONFIRM THE PRESENCE OF SEVERE COMMUNITY-
ACQUIRED PNEUMONIA IN A HOSPITAL SETTING?

1. Chest X-ray (Strong recommendation, high-grade evidence)

- PA-L: for children who can stand upright
- AP-L: acceptable for younger infants

2. Point-of-care chest ultrasonography (POCUS)

(Strong recommendation, high-grade evidence)
- 4 major abnormalities observed on CUS: pulmonary consolidation, positive air
bronchogram, abnormal pleural line, and pleural effusion
CLINICAL QUESTION #4
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT
DIAGNOSTIC AIDS WILL CONFIRM THE PRESENCE OF SEVERE COMMUNITY-
ACQUIRED PNEUMONIA IN A HOSPITAL SETTING?

3. Procalcitonin (PCT) (Conditional recommendation, moderate-grade evidence)

– to distinguish between bacterial and viral etiology, marker for
bacterial infection, disease severity, evaluation of patient’s response,
prevention of antibiotic overuse

4. Sputum Gram stain and culture

(Conditional recommendation, low-grade evidence)
CLINICAL QUESTION #5
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT CLINICAL AND ANCILLARY
PARAMETERS WILL DETERMINE THE NEED FOR ANTIBIOTIC TREATMENT?

Empiric antibiotic therapy is considered to be started in patients with

clinical signs and symptoms of PCAP with ANY of the following parameters:
(Conditional recommendation, low-grade evidence)

• Elevated WBC count

• Elevated CRP
• Elevated Procalcitonin
• Imaging findings of: alveolar infiltrates; or consolidation/air
bronchogram and/or pleural effusion in lung ultrasound
CLINICAL QUESTION #6
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT EMPIRIC TREATMENT IS EFFECTIVE
IF A BACTERIAL ETIOLOGY IS CONSIDERED?

For patients classified as having non-severe PCAP, regardless of

immunization status against Streptococcus pneumoniae and/or
Haemophilus influenzae type b (Hib):

1. Amoxicillin at 40-50mkD q8 x 7 days OR at 80-90mkD q12 x 5-7 days

2. Co-Amoxiclav at 80-90mkD q12 x 5-7 days OR

Cefuroxime at 20-30mkD q12 x 7 days
(with documented high level Penicillin-resistant pneumococci or beta-lactamase producing H.
influenzae base on data/hospital antibiogram)
CLINICAL QUESTION #6
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT EMPIRIC TREATMENT IS EFFECTIVE
IF A BACTERIAL ETIOLOGY IS CONSIDERED?
2. For patients classified as having severe PCAP, regardless of immunization status against
Streptococcus pneumoniae, any of the following is considered:

• Penicillin G at 200,000 units/kg/day Q6 if with complete Haemophilus influenzae type b

(Hib) vaccine OR Ampicillin 200mkD q6h if with no or incomplete Hib vaccination

• Cefuroxime 100mkD q8h OR Ceftriaxone 75-100mkD q12 to q24h OR Ampi-Sulbactam 200mkD

q6h (Ampi-based) (with documented high level Penicillin-resistant pneumococci or beta-lactamase
producing H. influenzae base on data/hospital antibiogram)

• Add Clindamycin 20-40mkD q6 to q8 when Staphylococcal pneumonia is highly suspected

based on clinical and chest radiograph features.
• Severe cases (sepsis/shock): Vancomycin 40-60mkD q6 to q8
CLINICAL QUESTION #6
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT EMPIRIC TREATMENT IS EFFECTIVE
IF A BACTERIAL ETIOLOGY IS CONSIDERED?
3. If with known allergy to Penicillin

• Non-Type 1 hypersensitivity: Cefuroxime PO 20-30mkD q12h OR Ceftriaxone at

75-100mkD q12h to q24 is considered

• Type 1 Hypersensitivity:
• Azithromycin 10mkD PO or IV q24h x 3 days OR 10mkD on Day 1 then 5mkD q24h
on Days 2-5
• Clarithromycin 15mkD q12 for 7 days
• Clindamycin at 10-40mkD PO or 20-40mkD q6 to q8 x 7 days
CLINICAL QUESTION #6
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT EMPIRIC TREATMENT IS EFFECTIVE
IF A BACTERIAL ETIOLOGY IS CONSIDERED?

4. When an atypical pathogen is highly suspected:

• Azithromycin 10mkD PO or IV q24h x 5 days

• Clarithromycin at 15mg/kg/day Q12 for 7 to 14 days
• Children <5 years old: Respiratory Syncytial Virus (RSV)
• All age groups: Streptococcus pneumonia

• Other important bacterial causes in children <5 y/o:

• H. influenzae
• S. pyogenes
• M. catarrhalis

• Children 5 y/o and older:

• Mycoplasma
• Clamydophila
CLINICAL QUESTION #7
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT TREATMENT IS EFFECTIVE IF A
VIRAL ETIOLOGY IS CONSIDERED?

Oseltamivir is strongly recommended to be started immediately within 36 hours of

laboratory-confirmed influenza infection.
(Strong recommendation, high-grade evidence)

(1) for children younger than 1 year old, 3mg/kg/dose;

(2) for 1 year and older, dose varies by child’s weight:
for 15kg or less, 30mg;
for >15 to 23 kg, 45mg;
for >23 to 40kg, 60mg;
and for >40kg, the dose is 75mg.
CLINICAL QUESTION #8
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT CLINICAL AND ANCILLARY
PARAMETERS WILL DETERMINE A GOOD RESPONSE TO CURRENT THERAPEUTIC
MANAGEMENT?

• Non-severe PCAP: clinical stability sustained for 24 hours, improvement

of cough, absence of febrile episodes within 24-72 hrs after initiation of
treatment (Conditional recommendation, very low-grade evidence)
CLINICAL QUESTION #8
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT CLINICAL AND ANCILLARY
PARAMETERS WILL DETERMINE A GOOD RESPONSE TO CURRENT THERAPEUTIC
MANAGEMENT?

• Severe PCAP; observed within 24-72hrs after initiation of treatment:

- Absence or Resolution of hypoxia - Resolution of tachycardia

- Absence or Resolution of danger signs - Resolving radiologic pneumonia
- Absence or Resolution of tachypnea - Resolving chest ultrasound findings
- Absence or Resolution of fever - Normal or Decreasing CRP
- Normal or Decreasing PCT
• Absolute clinical stability: resolution of ALL pneumonia-associated signs and
symptoms AND recovery to pre-pneumonia status

• Approaching clinical stability: resolution of ANY pneumonia-associated sign or

symptom OR delayed recovery to pre-pneumonia status

• Performing a follow-up chest Xray is NOT ROUTINELY DONE as long as there is

clinical improvement.
CLINICAL QUESTION #9
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT CAN BE DONE IF THE PATIENT IS
NOT RESPONDING TO CURRENT THERAPEUTIC MANAGEMENT?

For patients classified as having non-severe PCAP and are not improving or clinically worsening
within 24-72 hours after initiating therapeutic management, diagnostic evaluation is considered
to determine if any of the following is present: (Conditional recommendation, low-grade evidence)

1. Coexisting or other etiologic agents

2. Etiologic agent resistant to current antibiotic, if being given
3. Other diagnosis 1.3.1.Pneumonia-related complication
i. Pleural effusion
ii. Necrotizing pneumonia
iii. Lung abscess
4. Asthma
5. Pulmonary tuberculosis
CLINICAL QUESTION #9
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT CAN BE DONE IF THE PATIENT IS
NOT RESPONDING TO CURRENT THERAPEUTIC MANAGEMENT?

2. For patients as having non-severe PCAP and are not improving or clinically
worsening within 24-72 hours after initiating a therapeutic management:

and started on standard dose Amoxicillin at 40-50mg/kg/day, increasing the dose to

80-90mg/kg/day Q12 OR shifting to Amoxicillin-Clavulanate at 80-90mg/kg/day
(based on Amoxicillin content using a 14:1 amoxicillin:clavulanate formulation) Q12
OR Cefuroxime at 20-30 mg/kg/day Q12 is considered.
CLINICAL QUESTION #9
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT CAN BE DONE IF THE PATIENT IS
NOT RESPONDING TO CURRENT THERAPEUTIC MANAGEMENT?

adding a macrolide is considered when an atypical pathogen is highly suspected:

- Azithromycin at 10mg/kg/day PO or IV Q24 for 5 days (infants <6 months)

- Clarithromycin at 15mg/kg/day Q12 for 7 to 14 days
CLINICAL QUESTION #9
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS WITH
COMMUNITY-ACQUIRED PNEUMONIA, WHAT CAN BE DONE IF THE PATIENT IS
NOT RESPONDING TO CURRENT THERAPEUTIC MANAGEMENT?
The following diagnostic evaluations are considered in the presence of treatment failure in
severe CAP:

- cultures
- nucleic acid amplification test (PCR)
- serology
- imaging modalities (chest radiograph, UTZ, CT Scan)
- Biomarkers (CBC, CRP)

If patient is not improving after all alternative treatments, referral to a specialist is considered
CLINICAL QUESTION #10
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT
CLINICAL PARAMETERS WILL DETERMINE THAT SWITCH THERAPY CAN BE
CONSIDERED IN THE MANAGEMENT OF SEVERE COMMUNITY-ACQUIRED
PNEUMONIA?
Switch therapy is considered among patients with bacterial PCAP when ALL of the following
clinical parameters are present: (Conditional recommendation, low-grade evidence)

• Current IV antibiotic has been given for 24 hrs

• Afebrile for at least 8 hours without the use of antipyretics
• Able to feed and without vomiting or diarrhea
• Presence of clinical improvement as defined by ALL of the following:
- Absence of hypoxia
- Absence of danger signs
- Absence of tachypnoea
- Absence of fever
- Absence of tachycardia
CLINICAL QUESTION #11
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT
ADJUNCTIVE TREATMENT IS EFFECTIVE FOR COMMUNITY-ACQUIRED
PNEUMONIA?

1. Vitamins A is strongly recommended as adjunctive treatment for measles

pneumonia. (Strong recommendation, high-grade evidence)

2. Zinc and some mucokinetic agents is not considered as adjunctive treatment for
PCAP. (Conditional recommendation, low-grade evidence)

3. Vitamin D is not considered as adjunctive treatment for severe PCAP as it does not
reduce the length of hospital stay. (Conditional recommendation, low-grade evidence)
4. Bronchodilators are considered as adjunctive treatment for PCAP in the presence of
wheezing. (Conditional recommendation, expert opinion)
CLINICAL QUESTION #11
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 18 YEARS, WHAT
ADJUNCTIVE TREATMENT IS EFFECTIVE FOR COMMUNITY-ACQUIRED
PNEUMONIA?

6. There is insufficient evidence to recommend the use of the following

as adjunctive treatment for PCAP: (Very low-grade evidence)
- Oral folate
- Probiotics
- Vitamin C
- Virgin coconut oil (VCO)
- Nebulization with saline solution
- Steam inhalation
CLINICAL QUESTION #12
AMONG INFANTS AND CHILDREN AGED 3 MONTHS TO 3 YEARS, WHAT
INTERVENTIONS ARE EFFECTIVE FOR THE PREVENTION OF COMMUNITY-
ACQUIRED PNEUMONIA?

The following strategies are recommended to prevent PCAP:

- Vaccination against S.pneumoniae, Haemophilus influenzae type

b (Hib), Bordetella pertussis (pertussis), Rubeola virus (measles) and
Influenza virus (Strong recommendation; high-grade evidence)
- Breastfeeding: decreases incidence of pneumonia by 32%

- Avoidance of environmental tobacco smoke or indoor

biomass fuel exposure
- Zinc supplementation
Next report..