Pneumonie Ghid COPII

Guideline
Ministry of Health, NSW

73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059
Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/
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Infants and Children: Acute Management of Community Acquired

Pneumonia Clinical Practice Guideline
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Document Number GL2015_005
Publication date 19-Mar-2015
Functional Sub group Clinical/ Patient Services - Baby and child
Clinical/ Patient Services - Baby and child
Clinical/ Patient Services - Medical Treatment
Clinical/ Patient Services - Nursing and Midwifery
Summary Community Acquired Pneumonia (CAP) is a relatively common
presentation to emergency departments and correct management of CAP
improves patient outcomes. Infants and Children: Acute Management of
Community Acquired Pneumonia Clinical Practice Guideline provides a
guide for clinicians for the acute management of community acquired
pneumonia in infants and children.
Author Branch NSW Kids and Families
Branch contact NSW Kids and Families 02 9391 9764
Applies to Local Health Districts, Board Governed Statutory Health Corporations,
Specialty Network Governed Statutory Health Corporations, Affiliated
Health Organisations, Community Health Centres, Public Health Units,
Public Hospitals
Audience Emergency Departments, Nursing, Medical, Clinicians
Distributed to Public Health System, Divisions of General Practice, Government
Medical Officers, NSW Ambulance Service, Ministry of Health, Private
Hospitals and Day Procedure Centres, Tertiary Education Institutes
Review date 19-Mar-2020
Policy Manual Patient Matters
File No. H13/5231
Status Active
Director-General
GUIDELINE SUMMARY
INFANTS AND CHILDREN: ACUTE MANAGEMENT

OF COMMUNITY ACQUIRED PNEUMONIA
PURPOSE
The Infants and Children: Acute Management of Community Acquired Pneumonia
Clinical Practice Guideline has been developed to provide direction to clinicians and is
aimed at achieving the best possible paediatric care in all parts of the state. The Clinical
Practice Guideline was prepared for the NSW Ministry of Health by an expert clinical
reference group under the auspice of the state wide Paediatric Clinical Practice
Guideline Steering Group.
KEY PRINCIPLES
This guideline applies to all facilities where paediatric patients are managed. It requires
the Chief Executives of all Local Health Districts and specialty health networks to
ensure that this Clinical Practice Guideline or a locally adapted guideline based on this
guideline is in place in all hospitals and facilities required to assess or manage children
with community acquired pneumonia.
The clinical practice guideline reflects what is currently regarded as a safe and
appropriate approach to the acute management of community acquired pneumonia in
infants and children. However, as in any clinical situation there may be factors which
cannot be covered by a single set of guidelines. This document should be used as a
guide, rather than as a complete authoritative statement of procedures to be followed
in respect of each individual presentation. It does not replace the need for the
application of clinical judgement to each individual presentation.
USE OF THE GUIDELINE

Chief Executives must ensure:
Guidelines are in place in all hospitals and facilities likely to be required to

assess or manage paediatric patients with community acquired pneumonia
Ensure that all staff treating paediatric patients are educated in the use of the
locally developed paediatric guidelines.
Directors of Clinical Governance are required to inform relevant clinical staff treating
paediatric patients of this new guideline.
REVISION HISTORY
Version
March 2015
(GL2015_005)
GL2015_005
Approved by
Deputy Secretary,
Population and Public
Health
Amendment notes
New guideline
Issue date: March-2015
Page 1 of 2
GUIDELINE SUMMARY
ATTACHMENT
1. Infants and children Acute Management of Community Acquired Pneumonia Clinical
Practice Guideline.
GL2015_005
Page 2 of 2
INFANTS AND CHILDREN
Acute Management of
Community Acquired Pneumonia
CLINICAL PRACTICE GUIDELINE

1st edition
Issue date: March 2015
GL2015_005
NSW Kids and Families

73 Miller Street
NORTH SYDNEY NSW 2060
Tel. (02) 9391 9000
Fax. (02) 9391 9101
www.kidsfamilies.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the
inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale.
Reproduction for purposes other than those indicated above requires written permission from NSW Kids and
Families.
SHPN: (NKF)140484
ISBN: 978-1-74187-106-7
Further copies of this document can be downloaded from www.kidsfamilies.health.nsw.gov.au
NSW Health 2015
March 2015
A revision of this document is due in 2020
Infants and Children:

Acute Management of
CONTENTS
1
INTRODUCTION................................................................................................................... 1
OVERVIEW........................................................................................................................... 1
SCOPE OF THE GUIDELINE ............................................................................................... 2
ALGORITHM ........................................................................................................................ 3
SPECIFIC ANTIBIOTIC AND DOSE RECOMMENDATIONS ............................................... 4

5.1 NEONATES - 3 MONTHS ............................................................................................. 4
5.2 4 MONTHS - 16 YEARS................................................................................................ 4
5.3 4 MONTHS - 16 YEARS................................................................................................ 5
CLINICAL FEATURES ......................................................................................................... 6

6.1 History ........................................................................................................................... 6
6.2 Examination .................................................................................................................. 6
6.3 Viral vs Bacterial Pneumonia ......................................................................................... 7
6.4 Atypical Pneumonia....................................................................................................... 7
6.5 Alternative Diagnoses and Missed Diagnosis ................................................................ 7
6.6 Summary....................................................................................................................... 8
ASSESSMENT OF SEVERITY ............................................................................................. 8

7.1 Clinical features of mild pneumonia ............................................................................... 8
7.2 Clinical features of severe pneumonia ........................................................................... 8
7.3 Indications for admission to hospital .............................................................................. 9
DIAGNOSTIC TESTS ......................................................................................................... 11

8.1 Chest Radiography...................................................................................................... 11
8.2 Other Tests ................................................................................................................. 12
8.3 General investigations ................................................................................................. 12
MANAGEMENT .................................................................................................................. 15
9.1 General Management .................................................................................................. 15
9.2 Discharge Criteria........................................................................................................ 19
9.3 Follow up ..................................................................................................................... 19
9.4 Follow up Chest X-ray ................................................................................................. 19
10 COMPLICATIONS .............................................................................................................. 20
10.1 Pleural Empyema ........................................................................................................ 20
10.2 Lung Abscess.............................................................................................................. 21
11 APPENDICES ..................................................................................................................... 22
11.1 Appendix 1: References .............................................................................................. 22
11.2 Appendix 2: Incidence and Mortality ............................................................................ 24
11.3 Appendix 3: Prevention ............................................................................................... 26
11.4 Appendix 4: Resources ............................................................................................... 27
11.5 Appendix 5: Parent Information ................................................................................... 30
11.6 Appendix 6: Expert Working Group ............................................................................. 31
11.7 Appendix 7: Glossary .................................................................................................. 32
GL2015_005
Contents Page

Acute Management of
1 INTRODUCTION
These Guidelines are aimed at achieving the best possible paediatric care in all parts
of the State. The document should not be seen as a stringent set of rules to be
applied without the clinical input and discretion of the managing professionals. Each
patient should be individually evaluated and a decision made as to appropriate
management in order to achieve the best clinical outcome.
Field, M.J. and Lohr, K.N. (1990) define clinical practice guidelines as:
systematically developed statements to assist practitioner and patient
decisions about appropriate health care for specific clinical circumstances
(Field MJ, Lohr KN (Eds). Clinical Practice Guidelines: Directions for a New Program, Institute of Medicine,
Washington, DC: National Academy Press)
It should be noted that this guideline reflects what is currently regarded as a safe and
appropriate approach to care. However, as in any clinical situation there may be
factors which cannot be covered by a single set of guidelines and therefore this
document should be used as a guide rather than as an authoritative statement of
procedures to be followed in respect of each individual presentation. It does not
replace the need for the application of clinical judgment to each individual
presentation.
This document represents basic clinical practice guidelines for the acute
management of community acquired pneumonia in infants and children.
Local health districts and specialty health networks are responsible for ensuring that
local protocols based on these guidelines are developed. Local health districts and
specialty health networks are also responsible for ensuring that all staff treating
paediatric patients are educated in the use of the locally developed paediatric
guidelines and protocols.
In the interests of patient care it is critical that contemporaneous, accurate and
complete documentation is maintained during the course of patient management
from arrival to discharge.
Parental anxiety should not be discounted:
it is often of significance even if the child does not appear especially unwell.
2 OVERVIEW
Community Acquired Pneumonia (CAP) is a relatively common presentation to
emergency departments and correct management of CAP improves patient
outcomes. Cases of severe pneumonia due to strains of community Methicillinresistant Staphylococcus aureus (MRSA) are becoming more frequent in NSW.1,2
There has been a significant increase in the incidence of pleural effusion and
empyema. At the same time the risk of development of resistant organisms
increases with the use of broad spectrum antibiotics representing an argument
against the indiscriminate use of these drugs.
A Clinical Practice Guideline (CPG) for the management of CAP in adults was
developed by Hunter New England Health which prompted the consideration that a
Paediatric CPG for such a common condition might be useful throughout NSW.
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Members of the Greater Eastern and Southern Child Health Network Clinical
Practice and Guideline committee also requested that a CPG be developed for CAP.
The NSW Paediatric Clinical Practice Guideline Steering Group sent a letter to all the
NSW Area Health Services in February 2010 requesting advice re the development
of a CPG for CAP. Overall the feedback was very positive and supportive of the
development of guidelines in particular the need for consistent state-wide guidelines.
3 SCOPE OF THE GUIDELINE

Inclusions:
All children less than 16 years of age

Community acquired pneumonia.
Exclusions:
Sepsis (Refer to the Paediatric Sepsis Pathway)

Immunocompromised patients (where e.g. pneumocystis carinii pneumonia
(PCP) should be considered) cystic fibrosis
Herpes simplex virus pneumonitis
Hospital acquired pneumonia
Congenital heart or lung conditions
Tuberculosis, patients with recent overseas travel and tropical pneumonias
Premature babies who have NOT yet reached TERM as per their corrected
gestational age
Aspiration of foreign body and / or gastric contents
Non-cystic fibrosis bronchiectasis.
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4 ALGORITHM
Only need to meet 1 of the criteria to be assigned to that severity grade.
If multiple blue zone criteria present consider escalating to moderate severity
SEVERITY
ASSESSMENT
Effort of breathing
Respiratory Rate
Circulation
Oxygen saturation
MANAGEMENT
Oxygen
Antibiotics
MILD
MODERATE
SEVERE
Nil or Mild increase
Moderate increase
Severe increase
Blue zone SPOC

Within normal range
for age
White zone SPOC
No tachycardia
Yellow zone SPOC

Above range for age
Red zone SPOC

Continuing to rise, and or
evidence of exhaustion
Red zone SPOC
Shock / Red zone SPOC
95% in room air
<95% in room air
Yellow zone SPOC

Tachycardia
Failing to maintain Sp02

95% in 6L O2
OR
< 90% ( in air) Red Zone
SPOC
MILD
MODERATE
SEVERE
Not required
Oxygen to maintain
saturations above 95%
Oral antibiotics
IV if requires
admission or not
tolerating oral
High flow oxygen

(If available warm
humidified oxygen)
IV Antibiotics
See following pages for specific antibiotic and dose recommendations

Analgesics if required to relieve discomfort of fever or pain related to the
pneumonia
Hydration
Oral fluids
NG or IV if unable to
IV Fluids
tolerate oral fluids to
maintain hydration
Social situation
Family able to provide
Family unable to
N/A
appropriate care at
provide appropriate
home and can feed
observation at home,
normally/tolerate
unable to feed /tolerate
fluids
fluids
Analgesics
INVESTIGATIONS
MILD
MODERATE
SEVERE
Chest X Ray
No
Consider
Yes
Laboratory tests
No
Consider
Yes
Note: Infants <3 months with suspected CAP require full evaluation of sepsis
DISPOSITION
MILD
MODERATE
SEVERE
Decision to
hospitalise is an
individual one based
on age and clinical
factors
Outpatient / may be
discharged from ED if
all criteria met
Admit if < 3 months
old or family unable to
manage child at home
Consider Admission
Consult with SMO or
Paediatrician if not
clinically improved
within 24 hrs and
discuss transfer to
higher level facility
Admit, Senior doctor

review, escalate as per
local CERS
Consider NETS:
1300 36 2500
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Acute Management of
5 SPECIFIC ANTIBIOTIC AND DOSE RECOMMENDATIONS

5.1 NEONATES - 3 MONTHS
TREATMENT MILD
MODERATE
SEVERE
Neonates
<7days
BENZYLPENICILLIN
60mg / kg IV every 12hrs
PLUS
GENTAMICIN
4mg / kg IV once daily
BENZYLPENICILLIN
PLUS
GENTAMICIN
BENZYLPENICILLIN
PLUS
GENTAMICIN
Neonates
8 28 days
BENZYLPENICILLIN
PLUS
GENTAMICIN
BENZYLPENICILLIN
PLUS
GENTAMICIN
5mg / kg IV, once daily
BENZYLPENICILLIN
PLUS
GENTAMICIN
1 3 months
BENZYLPENICILLIN
(max dose 1.8g)
BENZYLPENICILLIN
(max dose 1.8g)
CEFOTAXIME
(max dose 2g)
PLUS
CLINDAMYCIN
10mg / kg IV every 8 hrs
(max dose 450mg)
OR
LINCOMYCIN
(max dose 600mg)
TREATMENT MILD
MODERATE
SEVERE
4 months
16 years
AMOXYCILLIN
15mg / kg oral every 8hrs
(max dose 1g)
CEFOTAXIME
(max dose 2g)
PLUS
CLINDAMYCIN
(max dose 600mg)
OR
LINCOMYCIN
(max dose 600mg)
ADD
VANCOMYCIN
15mg / kg IV every 6 hours
(max dose 750mg) if
intubated or septic.
5.2 4 MONTHS - 16 YEARS
GL2015_005
AMOXYCILLIN
(max dose 1g)
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Acute Management of
5.3 4 MONTHS - 16 YEARS

TREATMENT
MILD
MODERATE
SEVERE
CEFOTAXIME
(max dose 2g)
OR
CEFTRIAXONE
50 mg / kg /dose IV or
IM every 24 hours
(max dose 2 grams)
PLUS
VANCOMYCIN
(up to 750mg)
Staphylococcus
aureus
Pneumonia
*Note: Ceftriaxone NOT

recommended in
Neonates
Pertussis
(suspected or
confirmed at
any age)
GL2015_005
Consider
AZITHROMYCIN
10mg / kg oral once daily
for 5 days
(max dose 500mg)
OR
CLARITHROMYCIN
7.5mg / kg oral
every 12hrs
(max dose 250mg)
OR
ERYTHROMYCIN
for 714days
(max dose 500mg)
Consider
AZITHROMYCIN
for 5 days
(max dose 500mg)
OR
CLARITHROMYCIN
7.5mg / kg oral
every 12hrs
(max dose 250mg)
OR
ERYTHROMYCIN
10mg / kg oral, every 6hrs
for 714days
(max dose 500mg)
Consider
AZITHROMYCIN
for 5 days
(max dose 500mg)
OR
CLARITHROMYCIN
7.5mg / kg oral
every 12hrs
(max dose 250mg)
OR
ERYTHROMYCIN
10mg / kg oral, every
6hrs for 714days
(max dose 500mg)
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Acute Management of
6 CLINICAL FEATURES
An understanding and familiarity with the ways in which pneumonia may present is
paramount. The same illness can manifest in a variety of ways dependent on the age
of the child, the severity and the underlying micro-organism. This section refers to
the clinical features as elucidated on history taking and on examination. Additional
information on atypical pneumonia follows and finally some important points related
to alternative diagnoses are discussed.
6.1 History
Commonly, children with pneumonia present with fever, cough, an increased
respiratory rate (RR) and increased work of breathing.
The NSW Health Standard Paediatric Observations Charts Yellow Zone criteria
define tachypnoea as:
RR greater than 65 in infants less than 3 months
RR greater than 55 in infants aged 3 to 12 months
RR greater than 50 in children aged 1-4 years
RR greater than 35 in children aged 5-11 years
RR greater than 30 in children older than 12 years.
Tachypnoea is the most sensitive sign for predicting children who have pneumonia
evident on chest X-ray.3 Absence of tachypnoea makes pneumonia very unlikely. 3
In children over the age of one month, cough is the common symptom. The older
child may describe pleuritic pain.4
Fever is common but not always present at the time of assessment. Fever alone
occurring without cough and respiratory distress may still be pneumonia.5
Reduced oral intake and vomiting often occur as well as occasionally loose motions
or diarrhoea.
Some patient groups with underlying disease are at a greater risk for developing
pneumonia. Such diseases include cystic fibrosis, bronchiectasis, immunodeficiency
and conditions associated with recurrent aspiration. A careful history is needed in
those with recurrent pulmonary infections without known underlying disease.
Determination of the childs immunization status, recent travel and antibiotic use is
needed. These factors may provide clues to the organism as well as guide the
choice of antibiotic.
6.2 Examination
Vital signs are abnormal in proportion with disease severity; this includes increased
respiratory rate, increased heart rate or low oxygen saturation. Fever is often
present. The child may also be pale, diaphoretic and dry mucous membranes may
be present. The blood pressure is normal unless the pneumonia is very severe and /
or the child is profoundly dehydrated. Poor capillary refill and lethargy is evident in
children who are shocked.
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On inspection, increased work of breathing is present with the use of accessory

muscles, as evidenced by tracheal tug, subcostal and intercostal recessions. Infants
may also demonstrate nasal flare, head bobbing, grunting and episodes of apnoea.
Focal crackles on auscultation are not always present. 4 Even when focal crackles
are present, they are not sensitive nor specific for pneumonia. 6 Less commonly
bronchial breathing, a pleural rub or wheeze may be present. Reduced air entry and
dullness to percussion may occur in the presence of pleural effusion and empyema.
Late and serious signs include severe respiratory distress, cyanosis, hypotension,
and altered level of consciousness.
6.3 Viral vs Bacterial Pneumonia

Viral lower respiratory tract infection is more often associated with mild symptoms
and tends to occur in infants and younger children. The onset of symptoms for viral
pneumonia can be more insidious. Bilateral signs on auscultation are evident. There
may be rhinorrhoea, sore throat, arthralgia or a rash. Fever may be low-grade or
absent.4 Viral lower respiratory tract infections are often preceded by rhinorrhoea
and congestion.
In viral pneumonia temperatures are generally lower than in bacterial pneumonia.
Studies have shown a lower probability of having chest pain and rigors in viral
pneumonias.
Bacterial pneumonia, especially in older children, typically begins with a shaking chill
followed by high fever, cough and chest pain. Physical findings depend on the stage
of pneumonia. Early findings include scattered focal crackles and rhonchi heard over
the affected field. With progression of illness, signs of effusion and consolidation may
become evident.
6.4 Atypical Pneumonia

Although certain features on history and examination may be associated with
specific micro-organisms, there is no reliable way of distinguishing the causative
organism based on clinical features. 7 In atypical pneumonia, wheeze is more often
seen than in typical bacterial pneumonia.
Mycoplasma pneumoniae is more common in school-aged children than toddlers.
Patients with mycoplasma may describe a malaise, sore throat, dry cough,
headache, rash, myalgia and arthralgia associated with low-grade fever.4
Chlamydia pneumoniae usually presents with mild symptoms in adolescents and
younger children.
6.5 Alternative Diagnoses and Missed Diagnosis

There are a few other conditions that should be considered in children with this
presentation. Bronchiolitis in babies manifests with rhinorrhoea, fever and
tachypnoea. Bilateral crackles and / or wheeze may be evident. Children with upper
respiratory tract infections have normal saturations and a clear chest on auscultation.
Babies with cardiac failure often have a known history of congenital heart disease
and may have bilateral chest signs without fever. Urinary tract infection and
bacteraemia should be considered in children with fever who have minimal
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respiratory symptoms or signs. Tachypnoea alone may be a sign of underlying

metabolic acidosis e.g. diabetic ketoacidosis.
Occasionally, lower lobe pneumonia may present with abdominal pain and fever. In
these patients, the increased respiratory rate and low saturations may aid the
diagnosis, however these signs can be absent or minimal. Children with pneumonia
may also present with fever alone.
6.6 Summary
The clinical presentation of children with pneumonia varies widely based on the
childs age, disease severity and the causative organism. Pneumonia is common
and a high index of suspicion and careful attention to the findings on history and
examination will identify the majority of children with this illness.
7 ASSESSMENT OF SEVERITY
The objective of the initial clinical assessment is to decide if the childs history and
physical examination findings are suggestive of CAP. The severity of the condition
can range from mild to life threatening (see Table 1). Children with mild to moderate
respiratory symptoms can often be managed safely at home.
An assessment of pneumonia severity is necessary to determine the need for
laboratory and imaging studies and the appropriate treatment setting. The severity of
pneumonia is assessed by the child's overall clinical appearance and behaviour,
including an assessment of his or her degree of alertness and willingness to eat or
drink.8
7.1 Clinical features of mild pneumonia

These children:
Often have temperature less than 38.5 degrees celsius

Have mild or absent respiratory distress
May have an increased respiratory rate but will not display signs of dyspnoea
Have oxygen saturations greater than or equal to 94% in room air
They have no cyanosis
Are not tachycardic
Are mentally alert
Are able to feed normally.
7.2 Clinical features of severe pneumonia

These children:
Will often have temperatures greater than 38.5 degrees celsius and
Have moderate to severe respiratory distress with
Tachypnoea and moderate / severe increased work of breathing
May have grunting, nasal flaring or apnoea
May have cyanosis
May have altered mental status with hypoxaemia
May have tachycardia
May have an inability to feed or maintain hydration.
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7.3 Indications for admission to hospital

The decision to hospitalise a child with pneumonia must be an individual one based
on age and clinical factors. Hospitalisation should be considered for all infants less
than three months of age and for a child of any age whose family cannot provide
appropriate care and assure compliance with the therapeutic plan.
The age appropriate Standard Paediatric Observation Chart (SPOC) should be used
as part of the assessment to aid the clinician in determining how unwell the infant,
child or adolescent is and the severity of their illness. Escalating the childs care to
increasing the frequency of observations, Clinical Review or Rapid Response
according to the local CERS policy should be followed accordingly.
Additional indications for hospitalisation include: 9,10
Hypoxaemia (oxygen saturation consistently less than 93% in room air)
Dehydration, or inability to maintain hydration orally; inability to feed in an

infant
Moderate to severe respiratory distress:

o Respiratory rate greater than 55 breaths / minute in infants less than
12 months or
o Respiratory rate greater than 50 breaths / minute in older children
o Difficulty breathing, apnoea, or grunting
Toxic appearance (A "toxic" child appears drowsy, lethargic or irritable, pale,

mottled and / or tachycardic)11
Underlying conditions that may predispose to a more serious course of

pneumonia (e.g. cardiopulmonary disease)
Presence of complications (e.g. effusion / empyema)
Failure of outpatient therapy (worsening or no response in 24 to 72 hours)
Suspicion or confirmation that CAP is due to a pathogen with increased

virulence, such as Staphylococcus aureus or group A Streptococcus.
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Acute Management of
Table 112,13
Only need to meet 1 of the criteria to be assigned to that severity grade
vomiting excluded
If multiple blue zone criteria present consider escalating to moderate severity
Temperature (C): A temperature of greater than 38.5C with features of tachypnoea,
increased work of breathing, tachycardia and poor feeding can be indicators of
moderate to severe disease. Neonates and young infants may not have the
characteristic signs of serious infection (temperature can be high or low). 15
Severity
Assessment
Effort of
Breathing
Assessment of
Respiratory
Distress (SPOC)
Respiratory Rate
(breaths per
minute)
Mild
Moderate
Severe
Mild increase
Moderate increase
Severe, may exhibit

paradoxical chest
wall movement in
older child
Blue Zone SPOC
Yellow Zone SPOC
Red Zone SPOC
Within normal
range for age
Above range for age
Continuing to rise,
and/or signs of
exhaustion
Yellow Zone SPOC

White Zone SPOC
Circulation
Heart Rate
(beats per
minute)
Oxygen
Saturation
SpO2
Vomiting
Social Situation
GL2015_005
Red Zone SPOC
No tachycardia
Tachycardia
Shock
White Zone SPOC
Yellow Zone SPOC
Red Zone SPOC
95% in R.A.
<95% in R.A.
White Zone SPOC
Yellow Zone SPOC
Failing to maintain
Sp02 95% in 6L O2
Or
Red Zone SPOC
90% (in air)
No
May be present
May be present
Family able to
provide
appropriate
observations or
supervisions
Family unable to
provide appropriate
observations or
supervisions
N/A
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8 DIAGNOSTIC TESTS
The diagnosis of pneumonia requires historical or physical examination evidence of
an acute infectious process with signs or symptoms of respiratory distress or
radiologic evidence of an acute pulmonary infiltrate. The diagnostic approach
depends to some extent upon the setting (inpatient or outpatient) the severity of
illness and the age of the patient.
In the appropriate clinical setting the diagnosis can be made without radiographs.
In children with severe CAP the diagnosis should be confirmed by chest X-ray and a
full investigative process undertaken.
In general, aetiologic diagnosis should be sought in children who require admission
to hospital and those who fail to respond to initial treatment. 14
8.1 Chest Radiography

A Chest X-ray should not be considered a routine test in children with mild CAP.
Children that are well enough to be discharged from the ED with clear clinical signs
of pneumonia do not need a Chest X-ray to confirm the diagnosis.
However most children that require hospital admission will have moderate to severe
disease and will require a Chest X-ray.
It is recommended that Chest X-ray be obtained when:15,8
The pneumonia is classified as moderate to severe
Clinical findings are unclear
Exclusion of alternate explanation for respiratory distress (foreign body, heart

failure)
A complication such as pleural effusion is suspected
The pneumonia is prolonged and unresponsive to antimicrobials
In a rural setting where access to after-hours diagnostics is limited, or

decisions regarding escalation of care need to be made early.
There are a number of important points to consider when deciding whether to obtain
Chest X-ray in the context of CAP:
Radiologic findings are poor indicators of etiologic diagnosis
The finding of segmental consolidation is reasonably specific for bacterial

pneumonia but lacks sensitivity. Pulmonary consolidation in young children
sometimes appears to be spherical (round pneumonia). They tend to be
greater than 3cm, solitary, located posteriorly and mostly caused by
Streptococcus pneumoniae. They usually respond to appropriate antimicrobial
therapy
However if the lesion fails to resolve, a referral to a paediatric respiratory

service should be made for consideration of an alternate diagnosis. Alternate
diagnosis may include any of the following:
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o Congenital malformations of the lungs and airways (e.g. pulmonary

sequestration, bronchogenic cyst, congenital cystic adenomatoid
malformation)
o Thoracic tumors (e.g. bronchial carcinoid, bronchogenic carcinomas,
pleuropulmonary blastoma, metastatic Wilms tumor)
o Mediastinal masses (neurogenic tumor, lymphoma, enlarged
lymphnodes with tuberculosis)
o Predisposing conditions (e.g. foreign body inhalation, aspiration,
immune deficiencies)
o The findings of pneumatoceles or large effusions are supportive of
bacterial etiology. 15,8
Chest X-ray changes may lag behind clinical findings and ultrasound.
Chest X-ray views

The recommended view depends upon the age of the child. In children older than
four years the front posterior upright chest view is usually obtained to minimize the
cardiac shadow. In younger children the position does not affect the cardiothoracic
shadow, and the anterioposterior supine view is preferred.
Lateral Chest X-ray should not be routinely performed.
8.2 Other Tests

Ultrasound is simple, radiation-free, and is as good as Chest X-ray in identifying
pleuropulmonary alterations in children with suspected pneumonia. 16
8.3 General investigations

Pulse oximetry
Pulse oximetry should be performed in every child that presents with CAP. It is easy
to use, non-invasive and poses no health risk to the child. Hypoxaemia is well
established as a risk factor for poor outcome in children with systemic disease
especially respiratory disease. In a prospective study from Zambia the risk of death
from pneumonia was significantly increased when hypoxemia was present. 7
Continuous pulse oximetry in respiratory disease is important to monitor. A good
trace and trend is required continuously to accurately assess pulse oximetry, hence
the need to monitor continuous pulse oximetry and not one off spot checks.
Laboratory evaluation
The laboratory evaluation of the child with CAP depends on the clinical scenario,
age, severity of illness, presence of potential complications, underlying co
morbidities, and requirement for admission. As a general rule children who are
managed as outpatients do not require any investigations unless significant
comorbidities. Young infants (i.e. less than three months) in whom pneumonia is
suspected, particularly those who are febrile and toxic, require a full septic workup.
Refer to the Paediatric Sepsis Pathway.
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Acute Management of
Complete blood count

Table 2: When to perform complete blood count
IN MILD
PNEUMONIA
IN MODERATE
PNEUMONIA
IN SEVERE
PNEUMONIA
It is not necessary,
unless significant
co-morbidities i.e.
(immunodeficiency)
In children with moderate disease it may be

considered as it may provide useful information
in conjunction with the clinical presentation to
allow a decision to be made regarding
requirement for admission to hospital. White
blood cell counts greater than 15,000 per
microlitre are suggestive of bacterial disease;
eosinophilia may be present in children
infected with Chlamydia trachomatis.
Should be
undertaken in
all children
admitted with
severe CAP.
Acute phase reactants

ESR, CRP, serum procalcitonin do not distinguish between bacterial and viral
causes of CAP and should only be considered in moderate to severe disease. 17
In patients with moderate to severe disease, acute-phase reactants may be used in
conjunction with clinical findings to assess response to therapy.
Full blood count
Pointers:
Neutrophilia may occur in either bacterial or in some acute viral infections
Leucopaenia may occur with a viral infection or overwhelming sepsis or Q

fever (Coxiella burnetti)
Lymphocytosis Bordetella pertussis associated.
Urea and electrolytes

In moderate to severe disease only it may be helpful in assessing the degree of
dehydration and whether hyponatraemia is present.
Microbiological investigations
For children admitted to hospital with CAP it is important to attempt a microbiological
diagnosis. It is clear from a number of studies that between 10 to 30% of infections
will have a mixed viral and bacterial etiology. 18
Blood culture
Blood cultures should be obtained if the child requires admission to hospital. Blood
cultures are positive in 10 to 20% of children with pneumonia. The yield increases to
30 to 40% in patients with a parapneumonic effusion or empyema. Pneumococcal
pneumonia is seldom a bacteraemic illness. Streptococcus pneumoniae is cultured
in the blood in less than 5%.19
Blood cultures (ideally at least two separately collected sets) should be obtained in
children with moderate to severe CAP. Repeat blood cultures to document resolution
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Acute Management of
of bacteraemia should only be performed at 72 hours if the etiologic agent was

Staphylococcus-aureus. This should occur regardless of clinical status.
Sputum gram stain and culture
The Gram stain of a good sputum specimen (presence of leucocytes, absence of
squamous epithelial cells) has reasonable sensitivity and specificity for presumptive
detection of Streptococcus pneumoniae. However good specimens are often difficult
to obtain in children.19
Nasopharyngeal bacterial culture
This is uninformative and should not be routinely undertaken. Bacterial growth in the
nasoparynx does not indicate infection in the lower airways.
Nasopharyngeal aspirates
Nasopharyngeal secretions should be considered for viral detection using PCR and /
or immunofluorescence on all children less than 18 months admitted with CAP.
There is substantial evidence that the risk of serious bacterial infection is low in
children with laboratory confirmed viral infection. However, diffuse lower respiratory
tract inflammation induced by viral respiratory tract infections predispose to bacterial
super infection. Viral and bacterial co infections were detected in 23% of children
with pneumonia evaluated at a tertiary care childrens hospital.17
Antibacterial therapy is not necessary for children with a positive viral result in the
absence of clinical laboratory or radiographic findings suggestive of bacterial co
infection.
Sensitivity and specificity for PCR testing is over 90%.
Concordance between nasopharyngeal aspirates and nose throat swabs (taken for
viral studies) have been found to be 89%. 7
Pleural fluid
If expertise available pleural fluid may be aspirated for diagnostic purposes when
there is evidence of an effusion present. Ultrasound guided thoracocentesis is
preferred as it reduces the risk for iatrogenic pneumothorax.20 A specimen should be
sent for biology and virology. Culture positive rates are in the order of 1720%.
Ultrasound
Ultrasound is indicated as a first line investigation to confirm and quantify pleural
fluid and empyema if suspected clinically or radiologically. Lung abscesses located
within consolidated lung can also be visualized. Ultrasound is more sensitive than
chest X-ray for the detection of community-acquired pneumonia in children.16
Serological diagnosis
Urine should not be taken for pneumococcal antigenuria as the specificity is too poor
to be a useful test in diagnosis of CAP. False positivity occurs due to
nasopharyngeal pneumococcal colonisation.
Legionellosis is rare in childhood and so urinary antigen testing for that is rarely
indicated.
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Acute Management of
Serum
Paired serology remains the mainstay for diagnosing Mycoplasma pneumoniae and
Chlamydophila pneumoniae. Acute and convalescent serology should be undertaken
if the patient is admitted with severe pneumonia or the clinical presentation is
supportive of an infection with Mycoplasma or Chlamydia. During primary infection
IgM antibody appears 2-3 weeks after illness onset. IgG antibody may not reach a
diagnostically high (4 fold rise) titre until 6-8 weeks after illness onset.
9 MANAGEMENT
Consideration of the patients clinical condition using the Severity score and
Disposition Criteria (see algorithm page 5) will assist in determining whether the
child can be managed as an outpatient or if the child requires inpatient management.
Please note that this management guideline EXCLUDES the following conditions:
Sepsis, please refer to the Paediatric Sepsis Pathway

Immunocompromised patients (where Pneumocystis jiroveci should be
considered)
Cystic fibrosis
Aspiration pneumonia
HSV pneumonitis
Hospital acquired pneumonia
Congenital heart or lung conditions
Tuberculosis, patients with recent overseas travel and tropical pneumonias
Premature babies who are NOT TERM as per their corrected gestational age.
IMPORTANT NOTE:
Aboriginal and Torres Strait Islander children are particularly vulnerable to
Staphylococcal pneumonia and this should be taken into consideration when treating
these patients.
Consider Staphylococcus aureus pneumonia in any child with a severe
pneumonia not responding to antibiotic treatment. Please refer to the guidelines
below regarding antibiotic cover for Staphylococcus aureus pneumonia.
9.1 General Management

OUTPATIENT
MANAGEMENT:
INPATIENT MANAGEMENT:
Analgesia can be
given to relieve
discomfort from
fever or pain
related to the
pneumonia
Follow-up should
be arranged to
evaluate patient
for any
deterioration.
Analgesia can be given to relieve discomfort from fever or pain related to

the pneumonia
Oxygen should be provided to patients to keep their saturations above 94%
When oxygen therapy required, consider warm, humidified oxygen (if
available)
Patients exclusively on intravenous fluids require daily monitoring of their
electrolytes to monitor for SIADH 21
Chest physiotherapy has not been shown to be beneficial and is not
recommended 21
In ANY progressively unwell child, consideration should be given to transfer
the patient to a higher care facility. The advice / utilization of NETS 1300 36
2500 should be considered.
Specific Management: (see Drug Dose Guide in Appendix 4 for dose + route + interval)
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Acute Management of
Acute
Management of
Neonates
Infants
1 month
OUTPATIENT
MANAGEMENT:
Require
admission
follow inpatient
management.
Up to 7 days of age
BENZYLPENICILLIN (Penicillin G)
60 mg / kg IV every 12hrs
PLUS
GENTAMICIN 4mg/kg IV once daily
8 to 28 days of age
BENZYLPENICILLIN (Penicillin G)
40 to 60 mg /kg IV every 6hrs
PLUS
GENTAMICIN 5mg / kg IV once daily
NOTE: Herpes simplex virus pneumonitis may present between days 3 and 7 and requires
expert advice regarding management. 22 Consider ACICLOVIR if risk factors for HSV
pneumonitis 26
Consider adding the following treatments if Chlamydia trachomatis and Bordetella pertussis
(whooping cough) suspected, beware of atypical presentations e.g. apnoea.
AZITHROMYCIN 10mg / kg orally daily for 5 days
Infants
1 to 3 months
OUTPATIENT
MANAGEMENT:
Require
admission
follow inpatient
management.
For MILD to MODERATE pneumonia: 23

BENZYL PENICILLIN 30 to 45mg / kg IV
every 6hrs
Consider adding the following treatment
if Chlamydia trachomatis and pertussis
suspected. This is especially typical if the
patient is afebrile, only mildly unwell and
has the typical clinical features of
pneumonia. Treatment options: 23
For SEVERE pneumonia seek expert advice as

per local CERS and commence:
CEFOTAXIME 50mg / kg IV every 8hrs
PLUS
CLINDAMYCIN 10mg / kg IV every 8hrs
OR
LINCOMYCIN 15mg / kg IV every 8hrs
Consider adding AZITHROMYCIN 10mg / kg orally,
daily for 5 days (max. dose 500mg) if Chlamydia
trachomatis and Bordatella pertussis (whooping
cough) suspected.
AZITHROMYCIN 10mg / kg oral once

daily for 5 days (max. dose 500mg)
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Acute Management of
Community Acquired Pneumonia Acute Management of
4 months 16 years
Viral pneumonia is
most prominent in
this age group,
however if a bacterial
pneumonia is
suspected, antibiotic
therapy is required.
OUTPATIENT
MANAGEMENT:
For Mild disease use:

Amoxycillin 15mg / kg
oral every 8hrs
(max. dose 1g)
For Mild and Moderate pneumonia requiring

admission:
It is our recommendation that oral
AMOXYCILLIN be used as first line
treatment for patients admitted to hospital with
uncomplicated pneumonia. Oral
AMOXYCILLIN has been shown to be safe
and effective for inpatient treatment of CAP
and is recommended 7, 22
OR if Mycoplasma pneumoniae
suspected use:
CLARITHROMYCIN 7.5mg / kg
oral every 12hrs
(max. dose 250mg)
OR
ROXITHROMYCIN 4 mg / kg oral
every 12hrs
(max. dose 150mg)
If no response to treatment
review diagnosis, adherence
to treatment and if there is a
need for admission.
If infant/child is not tolerating
oral therapy, then intravenous
therapy (and hence
admission) is required.
PENICILLIN ALLERGY: Where
Penicillin allergy exists use
ROXITHROMYCIN or
ERYTHROMYCIN.
For SEVERE pneumonia seek expert

advice as per local CERS and
commence:
CEFOTAXIME 50mg / kg IV
every 8hrs
(max. dose 2g)
OR
CEFTRIAXONE 50 mg / kg
every 24 hours (max. dose 2 grams) IV
AMOXYCILLIN 15mg / kg oral, every 8hrs
or IM
(max. dose 1g)
PLUS
CLINDAMYCIN 10mg / kg IV
Treatment with intravenous Benzylpenicillin every 8hrs
(max. dose 450mg)
if oral therapy not tolerated (vomiting),
OR
septicaemia, complicated pneumonia or
LINCOMYCIN 15mg / kg IV
physician preference.
every 8hrs
BENZYLPENICILLIN 30 to 45mg / kg IV
every 6hrs (Cefotaxime or ceftriaxone may (max. dose 600mg)
be required if not responding to penicillin
PLUS if atypical pneumonia suspected:
alone).
AZITHROMYCIN 10mg / kg IV daily
If mycoplasma or other atypical suspected add: (max. dose 500mg)
CLARITHROMYCIN 7.5mg / kg oral
IF SIGNS OF SHOCK REFER TO
every 12hrs (max. dose 500mg)
PAEDIATRIC SEPSIS PATHWAY
OR
ROXITHROMYCIN 4mg / kg oral
every 12hrs (max. dose 150mg)
A patient on intravenous antibiotics can be
changed to oral amoxicillin or amoxycillin with
clavulanic acid (if Cefotaxime was required)
when tolerated and patient clinically improved.
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Acute Management of
Community Acquired Pneumonia Acute Management of
Staphylococcus
aureus Pneumonia
Pertussis
(suspected or
confirmed) at any
age 24
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OUTPATIENT
MANAGEMENT:
Infection tends to be severe

and require admission.
Staphylococcus aureus is usually suspected rather than confirmed however the

presence of pleural effusions, pneumatoceles or lung abscesses are more indicative
of Staphylococcal disease.
Admit all infants under 6

months with suspected pertussis
and children with cyanosis or
apnoea.
AZITHROMYCIN 10mg / kg oral,
daily for 5 days
OR (if older than 1 month)
CLARITHROMYCIN 7.5mg / kg
oral, every 12hrs
(max dose 250mg)
OR
ERYTHROMYCIN 10mg / kg oral,
every 6 hrs for 7-14 days (max
dose 500mg) (or erythromycin
ethylsuccinate formulation 20mg /
kg oral, every 6hrs for 7-14 days)
For suspected Staphylococcus aureus pneumonia:

There has recently been an increased incidence of community acquired MRSA.
Indigenous and Pacific Island children (and adults) tend to be at higher risk of
acquiring Staphylococcal infections.
Severely ill patients (with suspected or proven Staphylococcal Pneumonia) should be
treated for BOTH MRSA and NON MRSA pneumonia with CEFOTAXIME 50mg / kg
IV every 8hrs (max dose 2g) PLUS VANCOMYCIN 15 mg / kg IV every 6hrs (max
dose 750mg then adjust after trough level. Aim for trough level of 15-20 mg / L) until
sensitivities are known.
Consultation with the Respiratory Team +/- Infectious Diseases Team should be
considered.
Admit all infants under 6 months with suspected pertussis and children with cyanosis or
apnoea. Organise frequent observations and monitoring with pulse oximetry. Intensive
care may be needed for children with episodes of cyanosis or apnoea.
AZITHROMYCIN 10mg / kg oral, once daily for 5 days (max dose 500mg)
OR (if older than 1 month)
CLARITHROMYCIN 7.5mg / kg oral every 12hrs (max dose 250mg)
OR
ERYTHROMYCIN 10mg / kg oral, every 6 hrs for 7-14 days (max. dose 500mg)
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Acute Management of
9.2 Discharge Criteria

Patients are eligible for discharge when there is overall clinical improvement, good
oral intake, resolution of symptoms with consistent pulse oximetry measurements
greater than 94% for at least 12-24 hours.
Patients are not eligible for discharge if they have substantial increased work of
breathing or sustained tachypnoea or tachycardia. Parents should be able to
administer and children able to comply with taking oral antibiotics prior to discharge.
If a patient has had a chest tube, the chest tube should have been removed for at
least 24 hours prior to discharge.
9.3 Follow up
All patients with pneumonia require follow up examination with a medical officer at 46 weeks.
In patients with recurrent pneumonia or atelectasis consider:
Aspiration
Foreign body
Congenital malformation
Cystic fibrosis
Immunosuppression.
9.4 Follow up Chest X-ray

Follow up chest x-ray is not required in those who are previously healthy and
recovering well with no ongoing symptoms. In patients with uncomplicated
pneumonia repeat chest radiographs are unwarranted.
However in patients with pleural effusions, pneumatoceles, or pulmonary abscess a
repeat chest radiograph should be done to ensure resolution. In round pneumonia a
follow up chest radiograph should be done to ensure tumour masses are not missed.
A follow up chest x-ray is also warranted where there are continuing symptoms.
A chest x-ray should be obtained in children who fail to demonstrate clinical
improvement within 48 72 hours after initiation of antibiotic therapy or any child that
has progressive symptoms or clinical deterioration.
Repeat chest x-ray 4 6 weeks after diagnosis should only be obtained in patients
with recurrent pneumonia, round pneumonia or persisting symptoms (such as
shortness of breath, cough, fever or chest pain).
However it must be remembered that radiologic abnormalities lag behind clinical
resolution. Follow up chest x-ray obtained 3 - 6 weeks after initial imaging revealed
residual abnormalities in 10 30% of children with radiographically confirmed CAP. 25
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Acute Management of
10 COMPLICATIONS
10.1 Pleural Empyema
Pleural empyema is defined as accumulation of purulent material consisting of
leukocytes, fibrin, and pathogens between the visceral and parietal pleura. The
prevalence of empyema complicates 0.7% of childhood pneumonias with an
incidence of 0.7-3.3 per 100,000 in Australia.26
The clinical features may resemble those of uncomplicated pneumonia and in
addition include pleuritic (stabbing, worsening with deep inspiration) chest pain which
may occur due to inflammation of the parietal pleura. Radiation into ipsilateral
shoulder (paradiaphragmatic pleural empyema), and non-pleuritic pain (dull, aching)
signifies direct involvement of parietal pleura (e.g. abscess). On examination,
dullness on percussion, decreased/absent breath sounds, decreased chest
movements, scoliosis, and splinting may be present.
The aetiology is usually a bacterial infection, most commonly Streptococcus
pneumoniae and less commonly Staphylococcus aureus (MRSA/MSSA).
Diagnosis is suspected clinically and by chest X-ray and confirmed with chest
ultrasound. The collection of specimens (blood culture and pleural fluid) for
microbiological analyses is recommended as it may aid in guiding antibiotic
treatment even though in the majority of cases the cultures are negative. Empyema
commonly requires further interventions in addition to antibiotic treatment and as
such all children with empyema should be managed in a hospital with
appropriate expertise and under the care of a respiratory paediatrician (via
NETS).
The treatment consists of effective pain relief (NSAIDs; consider PCA/opioids postsurgery as indicated), maintaining appropriate oxygenation (SaO 2 > than 94%), and
antibiotics. Video-assisted thoracoscopic surgery (VATS) OR insertion of
percutaneous small bore drainage with instillation of fibrinolytics (e.g. 6 doses of
urokinase over 3 days) is often required.
Repeated ultrasounds may be required in the case of clinical deterioration as fluid
may accumulate rapidly. A prolonged course of oral antibiotics may be required (1-6
weeks) and follow-up until clinically improved should be arranged. Chest X-ray may
remain abnormal for up to 6 months after treatment. Usually children fully recover
without long term sequelae, however complications include:
Bronchopleural fistula
Cutaneous fistula
Bacteraemia
Peri/endocarditis
Pneumothorax
Necrotising pneumonia
Pneumatoceles
Persistent lobar collapse (? Foreign body)
Lung abscess.
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Acute Management of
Other Complications
Metastatic infection (i.e. in bones)
Sepsis
Haemolytic Uremic Syndrome (HUS).
10.2 Lung Abscess

A lung abscess is a cavity in the lung filled with purulent material caused by an
infection that arises from aspiration, impaired mucociliary clearance, or
haematogenous spread / septic emboli. Clinical symptoms and signs are often
indistinguishable from pneumonia, although persistent fever and cough despite
appropriate antibiotic treatment, chest pain, haemoptysis, dullness on percussion,
and localized reduced air entry may raise suspicion. Diagnosis is made by chest Xray and supported by chest ultrasound or contrast-enhanced chest computer
tomography. Lung abscess may require further radiological or surgical intervention in
addition to a prolonged course of antibiotic treatment, which is not only guided by
clinical severity but also preexisting risk factors (e.g. cover for anaerobics in children
at risk of recurrent aspirations, gram-negative bacilli in children with cystic fibrosis,
MRSA in children colonized with MRSA, recurrent skin abscesses, etc.) 2, 30.
A respiratory paediatrician (via NETS where necessary) should always be
consulted for children presenting with a lung abscess, as they commonly
require management in a hospital with appropriate expertise under the care of
a respiratory paediatrician.
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Acute Management of
11 APPENDICES
11.1 Appendix 1: References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
NSW Admitted Patient Data Collection (SAPHaRI). Centre for Epidemiology and
Evidence, NSW Ministry of Health, 2012.
NSW Emergency Department Data Collection (SAPHaRI). Centre for
Epidemiology and Evidence, NSW Ministry of Health, 2012.
Margolis, P., Gadomski, A. The rational clinical examination. Does this infant
have pneumonia? JAMA, 1998; 279 (4): 308.
http://emedicine.medscape.com/article/967822-clinical Paediatric Pneumonia
Clinical Presentation NJ Bennett. Viewed 23/11/11 4pm
Bachur, R., Perry, H., Harper, M.B. Occult pneumonias: empiric chest
radiographs in febrile children with leukocytosis. Ann Emerg Med, 1999; 33 (2):
166.
Mahabee-Gittens, E.M., Grupp-Phelan, J., Brody, A.S., Donnelly, L.F., Bracey,
S.E., Duma, E.M. Identifying children with pneumonia in the emergency
department. Clin Pediatr (Phila), Jun 2005; 44 (5): 427-35.
British Thoracic Society, Guidelines for Community Acquired Pneumonia in
Children, 2011.
Community Acquired Pneumonia Guideline Team, Cincinnati Children's Hospital
Medical Center. Evidence-based care guidelines for medical management of
community acquired pneumonia in children 60 days to 17 years of age
Guideline 2014. www.cincinnatichildrens.org/svc/alpha/h/health-policy/evbased/pneumonia.htm (last accessed on September 2014).
Bradley, J.S., Byington, C.L., Shah, S.S. The management of communityacquired pneumonia in infants and children older than 3 months of age: Clinical
practice guidelines by the Pediatric Infectious Diseases Society and the
Infectious Diseases Society of America. Clin Infect Dis, 2011; 53:e25.
Harris, M., Clark, J., Coote, N. British Thoracic Society guidelines for the
management of community acquired pneumonia in children: update 2011.
Thorax, 2011; 66:ii1.
NSW Ministry of Health, Infants and children: Acute Management of Fever,
second edition, 2010.
Hunter New England Local Health District, Emergency Department. Paediatric
Community Acquired Pneumonia Management Guidelines (Age 4 months 17
years). [Clinical Guideline] 2009.
NSW Health. Standard Paediatric Observation Charts. 2011
Up to date clinical features and diagnosis of community acquired pneumonia in
children May 2011 http://www.uptodate.com
Swingler, G.H. Randomised controlled trial of clinical outcome after chest
radiograph. Lancet, 1998; 351:404.
Caiulo, V. A., Gargani, L., Caiulo, S., Fisicaro, A., Moramarco, F., Latini, G.,
Picano, E. and Mele, G. Lung ultrasound characteristics of community-acquired
pneumonia in hospitalized children. Pediatric. Pulmonology (2012),.
doi: 10.1002/ppul.22585
The management of community acquired pneumonia in infants and children
older than 3 months of age. Clinical practice guidelines by the pediatric infectious
diseases society of America. Aug 2011.
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Acute Management of
18. Juven, T. Etiology of community- acquired pneumonia in 254 hospitalised
children. Pediatr Infect Dis J, 2000; 19: 217-223.

19. Korppi, M. Pneumococcal serology in childrens respiratory infections. Eur J Clin
Microbiol, 2008: 25: 559-560.

20. Barnes TW, Morgenthaler TI, Olson EJ, Sonographically guided thoracentesis
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
and rate of pneumothorax. Journal of Clinical Ultrasound 2005;33: 4426.

Francois P, Desrumaux A, Cans C, Prevalence and risk factors of suppurative
complications in children with pneumonia. Acta Paediatric 2010;99:8616.
eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2012 Jul.
Sydney Childrens Hospital Empiric Antibiotic Guideline (Intranet) 2012 update.
Guidelines for Pertussis, Sydney Childrens Hospital 2011.
Once Daily Gentamicin Practice Guideline, Sydney Childrens Hospital 2014.
Francoise, P., Desrumaux, A., Cans, C., Pavese, P. & Labarere, J. Prevalence
and risk factors of supparative complications in children with pneumonia. Acta
Paediatrica, 2010, 99: 861-866.
Strachan, Cornelius, Gilbert et al., Paediatric Empyema Thoracis, Pediatric
Respiratory Medicine, 2011 second edition, MOSBY Elsevier, Taussig and
Landau.
Thomas R, Ferguson J, Coombs GW, Gibson PG. Community-acquired
methicillin-resistant staphylococcus aureus pneumonia: a clinical audit.
Respirology. 2011; 16:926-31.
Commonwealth of Australia, Aboriginal and Torres Strait Islander Health
Performance Framework, 2011.
Pediatric Respiratory Medicine, second edition, MOSBY Elsevier, Taussig and
Landau, 2008.
Community Acquired Pneumonia Practice Guideline, Sydney Childrens Hospital
2013.
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Acute Management of
11.2 Appendix 2: Incidence and Mortality

Pneumonia in children worldwide is associated with significant morbidity and
mortality. Most paediatric deaths from pneumonia occur in developing countries, with
only low mortality reported in developed countries such as Australia. Over the past
decade, a trend of increasing complications of pneumonia (e.g. empyema) and the
emergence in the community of resistant strains of staphylococcal pneumonias are
reported.1,2,3 There are significant challenges in determining precise rates of viral and
bacterial CAP as well as identifying pathogens. It is likely that new pathogens will be
identified over the next decade. In many cases, there is a mixture of pathogens,
including both viral and bacterial pathogens with European and Asian studies
identifying 8 - 40% of mixed infections, while a pathogen is not detected in up to 60%
of cases.4
Age
The variety of pathogens, the developing immune system and age-related exposures
means that different pathogens are associated with different age groups. Vaccination
also plays a role in the incidence of pneumonia in children. See Table 1 (Appendix 4)
Infants under 1 year have the highest rate of hospitalisations for pneumonia in
developed countries such as Australia, with ill and preterm/low birth weight babies at
increased risk.5 In NSW from 2007 to 2011, 22 018 children under 17 years of age
were hospitalised with a diagnosis of pneumonia, with almost 34% of these children
aged between two and four years of age, and a further 32% aged under two years of
age.6 A 4% increase in presentations to NSW Emergency Departments (ED) for
pneumonia in children aged under 17 years has been reported for the five year
period 2007-11. Over 20 000 presentations to 82 NSW EDs occurred in this time
period, with the total number of cases likely to be much higher. 7
Pneumonia in the neonatal period is described as either early or late onset. Early
onset (within 72hrs of birth) is typically associated with maternal bacterial pathogens
and is acquired in three ways: from intrauterine aspiration of infected amniotic fluid;
from transmission across the placenta or from aspiration of infected amniotic fluid
either during or after birth.
Late onset pneumonia in the neonate occurs after the first week of life. It is
associated with nosocomial infection in hospitalised neonates, and thus is not
community-acquired. However, following discharge of the neonate it may then be
associated with colonisation from infected individuals in the community.
Causative organisms in the pre-school aged child are usually viruses, most
commonly respiratory syncytial virus (RSV), with streptococcus pneumonia the most
common bacterial agent. In children aged five years and older, the most common
pathogens are the bacteria Mycoplasma pneumoniae and Chlamydia pneumoniae.
Pathogens in Pleural Effusions, Empyema and Lung Abscess
Pleural effusions, empyema, lung abscess and other complications of pneumonia
have been reported to be increasing around the world 4, with one Australian study
identifying a majority of empyema cases caused by nonvaccine related strains of
Streptococcus pneumonia.2 Staphylococcal empyemas accounted for 9% of reported
cases, with over one third MRSA positive. 2 Community- acquired MRSA pneumonia
appears to be increasing in Australia and is implicated in more severe cases seen in
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Acute Management of
NSW in recent years, including those patients who have died. 3 Necrotising
pneumonia is associated with significant morbidity and mortality. 3,4 Causative
organisms responsible for necrotising pneumonia are Panton-Valentine leukocidin
(PVL) positive strains of MRSA and pneumococcal strains. PVL-positive MRSA
variants are usually associated with community-acquired infections that generally
affect previously healthy young children and young adults.
Risk Groups
Aboriginal and Torres Strait Islander children appear to be at increased risk.
Community acquired MRSA pneumonia was first reported in the 1980s amongst
indigenous communities in Western Australia.3 In almost 7% of paediatric pneumonia
hospitalisations in NSW, children were recorded as being from Aboriginal or Torres
Strait Islander background, though the actual figure is likely to be higher. 6 Other atrisk groups include children with pre-existing morbidity such as underlying cardiac
and respiratory conditions and immunocompromised children.
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Acute Management of
11.3 Appendix 3: Prevention

A major factor in the prevention of CAP is the general improvement in public health.
Ensuring adequate nutrition, preventing low birth weight and improved hand washing
have had good effects in the developed world. However much still needs to be done
to improve housing standards, crowding and smoking inside the house especially in
the Indigenous community. In addition to this, the uptake of routine vaccinations
needs ongoing emphasis by all health professionals.
Vaccination has had a major impact on pneumonia and child survival worldwide.
Haemophilus Influenzae type B vaccination has reduced radiologically confirmed
pneumonia by 20-30% in the developing world.
Bordetella pertussis continues to be seen and NSW continues to experience
frequent epidemics. Infants less than six months have the highest morbidity and
mortality. While improved uptake of the primary pertussis vaccination helps prevent
cases, another important factor is the increasing pool of susceptible older children
and adults. Therefore a booster vaccination is given at four years and in high school
(years 7 or 10). A booster vaccination is also recommended for all parents planning
a pregnancy, all household members, carers and grandparents of infants under 12
months, and all adults working with young children, especially health care and child
care workers.
Note that acellular pertussis vaccines available in Australia that contain three
pertussis antigens are 85% effective in preventing pertussis and between 71% and
78% effective in preventing mild disease however immunity wanes over time. This
means that even fully immunised children can still develop whooping cough
(although they often have less severe illness).
Streptococcus pneumoniae. The introduction of the pneumococcal conjugate
vaccine (PCV) has been the biggest recent change in pneumonia prevention. These
vaccines are immunogenic in children from two months of age and have around 97%
efficacy against invasive pneumococcal disease. Recently Prevenar 13 has replaced
Prevenar 7 on the National Immunisation Program. Prevenar 13 provides protection
against six additional serotypes, including serotype 19A, which is the dominant
serotype responsible for invasive pneumococcal disease (IPD) in children under
three years in recent years in Australia.
Influenza is a common cause of CAP and children are important in the spread of
influenza in the community. Annual seasonal influenza vaccination is recommended
for any person aged six months and over who wishes to reduce the likelihood of
becoming ill with influenza, but is only available for free for all adults aged 65 and
over, all Aboriginal and Torres Strait Islander peoples aged 15 years and over, all
pregnant women and children aged six months and over with medical conditions
predisposing them to severe influenza.
RSV prophylaxis with monoclonal RSV immunoglobulin can decrease the risk of
severe pneumonia in high risk infants. Recent analysis has suggested that
Palivizumab may be cost effective in selected high risk infants.
GL2015_005
Page 26 of 32

Acute Management of
Acute
Community Acquired PneumoniaManagement of
11.4 Appendix 4: Resources

Table 1: Pathogens by Age
Adapted from Ostapchuk, Roberts & Haddy, 2004 and Therapeutic Guidelines, 2010 (page 232)
Age
Common Bacterial
< 1 week
Common Viral
Streptococcus agalactiae
(group B streptococcus)
Escherichia Coli
Listeria monocytogenes
Less Common
bacterial
Less common Viral
Herpes simplex virus

Cytomegalovirus
Influenza
Enterovirus
Adenovirus
Cytomegalovirus
Varicella-zoster virus
Adenovirus
Epstein-Barr virus
Respiratory syncytial
virus
Parainfluenza
Varicella-zoster virus
1 week to
3 months
4 months to
5 years
6 years to
adolescence
Streptococcus pneumoniae
Chlamydia trachomatis
Chlamydophila
pneumoniae
Chlamydophila pneumonia
Mycoplasma pneumoniae
Mycoplasma pneumoniae
Chlamydophila pneumonia
Haemophilus influenzae
(non-typeable)
Respiratory syncytial virus

Adenovirus
Influenza virus
Parainfluenza virus 1, 2, 3
Other
Influenza
RSV
Parainfluenza
Metapneumovirus
Other
Influenza
Adenovirus
Other
GL2015_005
GL2015_005
Staphylococcus
aureus
Group D
Streptococci
Haemophilus (H)
influenzae
Streptococcus
pneumoniae
Bordetella pertussis
Staphylococcus
aureus
Haemophilus
influenzae type B
Staphylococcus
aureus
Haemophilus
influenzae B
Moraxella catarrhalis
Q fever (Coxiella
burnetti)
Staphylococcus
aureus
Streptococcus
pyogenes (group A)
Q fever (Coxiella
burnetti)
Page 27 of 32
Page 27 of 32

Acute Management
of
Acute Management
of Community Acquired
Pneumonia
Table 2: Neonatal Drug Doses (aged 7 28 days)

Drug name
Route
Dose
Interval
Aciclovir
IV
20 mg/kg
Every 8 hrs
Azithromycin
Oral
10 mg/kg
Once daily
Benzyl penicillin (Penicillin G)

Age less than 7 days
IV or IM
60-120 mg/kg
Every 12 hrs

Age 7 to 28 days
IV or IM
60-120 mg/kg
Every 6 hrs
Gentamicin
Age less than 7 days
IV or IM
* Initial dosing with IM can be
given if IV access not available
4 mg/kg
Once daily
Gentamicin
Age 7 to 28 days
IV or IM
* Initial dosing with IM can be
given if IV access not available
5 mg/kg
Once daily
GL2015_005
GL2015_005

Page 28 of 32
Page 28 of 32
Infants and Children: Infants and Children:

Acute Management
of
Acute Management
of Community Acquired
Community Acquired PneumoniaPneumonia
Table 3: Paediatric Antimicrobial Doses (aged > 1 month up to 16 years)

Drug name
Route
Dose
(max. weight for calculations
= 40 kg)
Interval
Dose Limit
Amoxycillin
Oral
15 mg/kg
Every 8 hrs
1g
Amoxycillin and Clavulanate (7:1)

(Augmentin DuoTM)
Oral
22.5 mg (amoxicillin)/kg
Every 12 hrs
875 mg
Amoxycillin and Clavulanate (4:1)

(AugmentinTM)
Oral
15 mg (amoxicillin)/kg
Every 8 hrs
600 mg
Azithromycin
Oral
10 mg/kg
Once daily
500 mg
IV or IM*
60 mg/kg
Every 6 hrs
1.8 g
Cefotaxime
IV or IM*
50 mg/kg
Every 8 hrs
2g
Ceftriaxone
IV or IM
50 mg/kg
Every 2 hrs
2g
Clarithromycin
Oral
7.5 mg/kg
Every 12 hrs
500 mg
Clindamycin
IV or IM*
10 mg/kg
Every 8 hrs
450 mg
Erythromycin
Oral
10 mg/kg
Every 6 hrs
500 mg (multiple drug interactions)
Lincomycin
IV
15 mg/kg
Every 8 hrs
600 mg
Roxithromycin
Oral
4 mg/kg
Every 12 hrs
150 mg
Vancomycin
IV only
15 mg/kg
Every 6 hrs
750 mg
*IM therapy only until IV line established
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Page 29 of 32

Acute Management of Community Acquired
Pneumonia
11.5 Appendix 5: Parent Information

Parents and carers should be provided with verbal and written information about
pneumonia on discharge. A range of factsheets on health and safety topics have been
developed by Sydney Children's Hospitals Network and Kaleidoscope Hunter Childrens
Health Network. Access to the Pneumonia fact sheet can be found at:
http://www.schn.health.nsw.gov.au/parents-and-carers/fact-sheets/pneumonia
GL2015_005
Page 30 of 32

Pneumonia
11.6 Appendix 6: Expert Working Group

Dr Mark Lee (Chair)
Director Emergency,
John Hunter Childrens Hospital,
Paediatrician, HNELHD
Helen Stevens
Paediatric Clinical Nurse Consultant,

Childrens Healthcare Network, HNELHD
Dr Maureen Van Rossumdu Chattel
Paediatrician,
Manning Rural Referral Hospital (Taree)
Professor Joerg Mattes
Respiratory & Sleep Medicine Paediatrician

John Hunter Childrens Hospital,
Chair - Paediatrics and Child Health School of
Medicine and Public Health,
The University of Newcastle
Melinda Simpson-Collins
Paediatric Clinical Nurse Consultant,

Childrens Healthcare Network, NSLHD
Tina Kendrick
Paediatric Clinical Nurse Consultant, NETS
Dr Miguel Taliana (part)
Emergency Physician (FACEM),

Maitland Hospital
Dr Mandy Fletcher
Fellow Paediatric Emergency Medicine,

Sydney Childrens Hospitals Network,
Randwick
Sarah Patterson
(Secretariat until February 2014)
Project Officer,
Paediatric Clinical Practice Guidelines
Co-ordinator,
Clinical Excellence Commission
Professor Alison Kesson
Department Head Infectious Diseases and

Microbiology and Chair, Diagnostic Division,
Westmead
Jane Cichero
(Secretariat from February 2014)
Paediatric Guideline Coordinator

NSW Kids and Families
Acknowledgement given to the following expert for specific input:

Dr Jim Newcombe
Infectious Diseases Fellow,
Randwick, & Royal Prince Alfred Hospital
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Page 31 of 32

Pneumonia
11.7 Appendix 7: Glossary

BGL
ED
CNS
CSF
CRP
CT
DI
DIC
Diff
ESR
FBC
Blood glucose level

Emergency department
Central nervous system
Cerebrospinal fluid
C-reactive protein
Computed tomography
Diabetes insipidus
Disseminated intravascular coagulation
Differential
Erythrocyte sedimentation rate
Full blood count
FDPs
Fibrin degradation products
GCS
Hib
HSV
Glasgow Coma Scale

Haemophilus influenzae type b
Herpes Simplex Virus
IgG
IgM
Immunoglobulin G
Immunoglobulin M
IM
IV
LFTs
LP
MRI
MRSA
MSSA
MTB
M/C/S
Na+
NETS
NHMRC
PCP
PCR
PPE
PHU
PMN
RBC
SIADH
WBC
WCC
Intramuscular
Intravenous
Liver function tests
Lumbar puncture
Magnetic resonance imaging
Methicillin-resistant Staphylococcus aureus
Methicillin-sensitive Staphylococcus aureus
Mycobacterium tuberculosis
Microscopy, culture and sensitivity
Serum sodium
NSW Newborn and paediatric Emergency Transport Service
National Health and Medical Research Council
Pneumocystis carinii pneumonia
Polymerase chain reaction
Personal protective equipment
Public Health Unit
Polymorphonuclear
Red blood cell
Syndrome of inappropriate antidiuretic hormone
White blood cell
White cell count
GL2015_005
Page 32 of 32

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Guideline

Ministry of Health, NSW

Infants and Children: Acute Management of Community Acquired

INFANTS AND CHILDREN: ACUTE MANAGEMENT

USE OF THE GUIDELINE

Guidelines are in place in all hospitals and facilities likely to be required to

Issue date: March-2015

Issue date: March-2015

INFANTS AND CHILDREN

CLINICAL PRACTICE GUIDELINE

Issue date: March 2015

NSW Kids and Families

Infants and Children:

SCOPE OF THE GUIDELINE ............................................................................................... 2

SPECIFIC ANTIBIOTIC AND DOSE RECOMMENDATIONS ............................................... 4

CLINICAL FEATURES ......................................................................................................... 6

ASSESSMENT OF SEVERITY ............................................................................................. 8

DIAGNOSTIC TESTS ......................................................................................................... 11

Issue date: March-2015

Infants and Children:

Issue date: March-2015

Infants and Children:

3 SCOPE OF THE GUIDELINE

All children less than 16 years of age

Sepsis (Refer to the Paediatric Sepsis Pathway)

Issue date: March-2015

Infants and Children:

Nil or Mild increase

Blue zone SPOC

Yellow zone SPOC

Red zone SPOC

95% in room air

<95% in room air

Yellow zone SPOC

Failing to maintain Sp02

High flow oxygen

See following pages for specific antibiotic and dose recommendations

Admit, Senior doctor

Issue date: March-2015

Infants and Children:

5 SPECIFIC ANTIBIOTIC AND DOSE RECOMMENDATIONS

5.2 4 MONTHS - 16 YEARS

Issue date: March-2015

Infants and Children:

5.3 4 MONTHS - 16 YEARS

*Note: Ceftriaxone NOT

Issue date: March-2015

Infants and Children:

RR greater than 65 in infants less than 3 months

RR greater than 55 in infants aged 3 to 12 months

RR greater than 50 in children aged 1-4 years

RR greater than 35 in children aged 5-11 years

RR greater than 30 in children older than 12 years.

Issue date: March-2015

Infants and Children:

On inspection, increased work of breathing is present with the use of accessory

6.3 Viral vs Bacterial Pneumonia

6.4 Atypical Pneumonia

6.5 Alternative Diagnoses and Missed Diagnosis