PCAP

1.WHO SHALL BE CONSIDERED AS HAVING COMMUNITY-ACQUIRED PNEUMONIA?

 presenting with cough and/or respiratory difficulty may be evaluated for possible
presence of pneumonia
 ER
 O2 sat < 94% at room air in 3 mo to 5 years, and >5 years old without any comorbid
conditions affecting oxygenation
 Tachypnea
 Chest wall retractions
 Fever, grunting, wheezing, decreased breath sounds, nasal flaring, cyanosis, crackles or
localized chest findings at any age
 Consolidation in ultrasound
o Chest x-ray may be requested
 Dehydration in a patient aged 3 months to 5 years
 High index of clinical suspicion

2.WHO SHALL BE CONSIDERED AS HAVING COMMUNITY-ACQUIRED PNEUMONIA?

1. classified as pCAP A, B, C or D within 48 hours after consultation

2. patient initially pCAP A or B but not responding to current treatment after 48 hours maybe admitted
3. patient classified as pCAP C may be
3.1. admitted to the regular ward
3.2. managed initially as outpatient if the ff are not present:
3.2.1. < 2 years old.
3.2.2. Convulsion
3.2.3. Chest x-ray with effusion, lung abscess, air leak or multilobar consolidation.
3.2.4. Oxygen saturation < 95% at room air.
4. A patient classified as pCAP D may be admitted to a critical care unit
 3.WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT CLASSIFIED AS EITHER pCAP A
or pCAP B BEING MANAGED IN AN AMBULATORY SETTING?

4.WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT CLASSIFIED AS EITHER pCAP C
or pCAP D BEING MANAGED IN A HOSPITAL SETTING?

DIAGNOSTICS pCAP A pCAP B pCAP C pCAP D

1. assessment of gas exchange - Oxygen saturation using pulse oximetry

2. microbial determination of - Gram stain and/or - Gram stain and/or - Gram stain and/or
underlying etiology aerobic culture and aerobic culture and aerobic culture and
sensitivity of sensitivity of sputum, sensitivity of sputum,
sputum nasopharyngeal aspirate tracheal aspirate and/or
and/or pleural fluid, pleural fluid, for pCAP
may not be and/or blood for pCAP C D
requested with lung abscess,
- Blood culture and empyema or
sensitivity pneumothorax
- Anaerobic culture and
- Anaerobic culture and
sensitivity of sputum,
sensitivity of sputum,
nasopharyngeal
nasopharyngeal
aspirate, pleural fluid,
aspirate, pleural fluid,
and/or blood culture and
and/or blood culture and
sensitivity for
sensitivity for
o pCAP D
o pCAP C with lung
abscess,
empyema or
pneumothorax
- Serum IgM for Mycoplasma pneumoniae
3. clinical suspicion of necrotizing - Chest x-ray PA-lateral
pneumonia, multilobar - Chest ultrasound
consolidation, lung abscess, pleural
effusion, pneumothorax or
pneumomediastinum.
4. Surrogate markers for possible - CRP
presence of pathogens requiring may not be - PCT
initial empiric antibiotic with requested - Chest x-ray PA-lateral
microbiology as the reference - CRP - WBC
standard - PCT
- WBC

5. determination of metabolic - pH in arterial blood gas for metabolic acidosis

derangement for immediate - Serum sodium for hyponatremia
correction - Serum potassium for hypokalemia

5.WHEN IS ANTIBIOTIC RECOMMENDED?

1. For pCAP C, empiric antibiotic may be started if any of the following is present.
 Elevated serum C-reactive protein [CRP] [
 serum procalcitonin level [PCT]
 white blood cell [WBC] count greater than 15,000
 lipocalin 2 [Lpc-2]
 Alveolar consolidation on chest x-ray
 Persistent high-grade fever without wheeze
2. For pCAP D, a specialist may be consulted
6.WHAT EMPIRIC TREATMENT SHOULD BE ADMINISTERED IF A BACTERIAL ETIOLOGY IS STRONGLY
CONSIDERED?

PCAP A or B
 without previous antibiotic Amoxicillin trihydrate
 regardless of immunization  40-50 mg/kg/day, max dose of
status to Hib and S. 1500 mg/day in 3 divided doses
pneumoniae (areas with low antibiotic
resistance to amoxicillin)
 90 mg/kg/day (areas with
proven high amoxicillin
resistance)
 may be given for a minimum of
3 days
 may be given in 2 divided
doses for a minimum of 5 days
Azithromycin  may be given if there is
 10 mg/kg/day OD for 3 days, or known hypersensitivity to
 10 mg/kg/day at day 1 then 5 amoxicillin
mg/ kg/day for day 2 to 5  suspicion of atypical
 maximum dose of 500 mg/day organisms particularly
Clarithromycin Mycoplasma pneumoniae
 15 mg/kg/day in 2 divided doses
for 7 days
 maximum dose of 1000 mg/day
PCAP C
 without previous antibiotic Penicillin G
and requiring  100,000 units/kg/day in 4
hospitalization divided doses
 completed the primary
immunization against Hib
 has not completed the Ampicillin
primary immunization, or  100 mg/kg/day in 4 divided
immunization status doses
unknown, against
Hib
 can tolerate oral feeding Amoxicillin
and does not require  40-50 mg/kg/day areas of
oxygen support proven low amoxicillin
resistance
 90 mk/kg/day in areas of proven
high amoxicillin resistance
 maximum dose of 1500 mg/day
in 3 divided doses for at most 7
days
PCAP D  a specialist may be consulted
MRSA  vancomycin may be started
 specialist may be consulted
7.WHAT TREATMENT SHOULD BE INITIALLY GIVEN IF A VIRAL ETIOLOGY IS STRONGLY CONSIDERED?

PCAP ABCD Non-influenza virus suspected antiviral drug therapy

may not be beneficial
PCAP Cor D influenza virus clinically suspected Reduce time to symptom resolution
or laboratory confirmed
Oseltamivir
 infants 3-8 months old at 3 mg/kg per dose
twice daily x 5 days
 infants 9-11 months old at 3.5 mg/kg per dose
twice daily x 5 days
 >12 months old: body weight
o <15 kg at30 mg twice daily x 5 days
o >15-23 kg at 45 mg twice daily x 5
days
o >23-40 kg at 60 mg twice daily
x 5 days
o >40 kg at 75 mg twice daily x 5 days;
 doses to be started within 48 hours of onset of
influenza-like symptoms
Zanamivir
 >7 years old at 10 mg (two 5-mg inhalations)
twice daily x 5 days,
within 36 hours of onset of influenza-like
symptoms.

8. WHEN CAN A PATIENT BE CONSIDERED AS RESPONDING TO CURRENT THERAPEUTIC MANAGEMENT?

PCAP A or B may be assessed within 24-48 hours o cough has improved or

after consultation o body temperature has returned to normal
PCAPC be assessed within 24-48 hours after any of the ff physiologic parameters has
admission significantly improved or returned to normal
o Respiratory rate
o Oxygen saturation at room air using
pulse oximetry
o Body temperature in Celsius
o Cardiac rate at full minute
o Work of breathing
PCAP D may be assessed within 48-72 hours all of the ff physiologic parameters has
after admission significantly improved
o Respiratory rate
o Oxygen saturation at room air using
pulse oximetry
o Body temperature in Celsius
o Cardiac rate at full minute
Work of breathing
o Good clinical response to current therapeutic management may not require chest x-
ray or complete blood count to document treatment success at end of treatment
9. WHAT SHOULD BE DONE IF A PATIENT IS NOT RESPONDING TO CURRENT THERAPEUTIC
INTERVENTION?

diagnostic evaluation to determine if any of the

following is present
pCAP A or B not improving, or clinically worsening  Coexisting or other etiologic agents
within 72 hours after initiating a  Etiologic agent resistant to current antibiotic, if
therapeutic intervention being given
[treatment failure]  Other diagnosis
o Pneumonia-related complication
o Necrotizing pneumonia
o Pleural effusion
o Asthma
o Pulmonary tuberculosis

pCAP C not improving, or clinically worsening,  Coexisting or other etiologic agents

within 48 hours after initiating a  Etiologic agent resistant to current antibiotic, if
therapeutic intervention [treatment being given
failure]  Other diagnosis
o Pneumonia-related complication
o Acute respiratory failure
o Pleural effusion
o Pneumothorax
o Necrotizing pneumonia
o Lung abscess
o Asthma
o Pulmonary tuberculosis
o Sepsis
pCAP D clinically worsening within 24 hours after  referral to a specialist may be done
initiating a therapeutic intervention

10. WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA BE STARTED?

1. pCAP C: switch from IV antibiotic administration to oral form may be beneficial to reduce length of hospital stay
provided all of the following are present
 Current parenteral antibiotic has been given for at least 24 hours
 At least afebrile within the last 8 hours without current antipyretic drug
 Responsive to current antibiotic therapy as defined in Clinical Question 8
 Able to feed, and without vomiting or diarrhea
 Without any current pulmonary [effusion / empyema, abscess, air leak, lobar consolidation or
necrotizing pneumonia] or extrapulmonary [meningitis or sepsis] complications
 Oxygen saturation > 95% at room air
2. pCAP D, referral to a specialist may be done if switch therapy is considered
11. WHAT ANCILLARY TREATMENT CAN BE GIVEN?

May be benifcial May not be beneficial

pCAP A or B  Oral steroid in a patient with  Cough preparation or
coexisting asthma parenteral steroid in a patient
 Bronchodilator in the presence without asthma
of wheezing  Elemental zinc, vitamin D3 and
probiotic
pCAP C  Use of either nasal catheter or  Zinc supplement in reducing
nasal prong in administering treatment failure or length of
oxygen hospital stay
 Zinc supplement in reducing  Vitamin D3 in reducing length
mortality of hospital stay
 Use of bubble CPAP instead of  Parenteral steroid, probiotic,
low flow oxygen in improving virgin coconut oil, oral folate
oxygenation and nebulization using saline or
 Steroid or spirulina in reducing acetylcysteine
length of stay
 Oxygen for oxygen saturation
below 95% at room air in
improving oxygenation
pCAP D  referral to a specialist may be
beneficial

12. HOW CAN PNEUMONIA BE PREVENTED?

The following are beneficial in reducing the burden of hospitalization because of pneumonia.

1. Conjugated vaccine [PCV 10 or 13] against Streptococcus pneumoniae

2. Vaccine against Hib and Diphtheria, Pertussis, Rubeola and Varicella
3. Breastfeeding
4. Avoidance of cigarette smoke and biomass fuel

The following are not beneficial in reducing the clinical impact of pneumonia.

1. Zinc supplement
2. Vitamin D