Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

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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 and the Infectious Diseases Society of America

The British Thoracic Society first published management guidelines for community acquired pneumonia in children in 2002 and covered available evidence to early 2000. These updated guidelines represent a review of new evidence since then and consensus clinical opinion where evidence was not found. This document incorporates material from the 2002 guidelines and supersedes the previous guideline document.

https://thorax.bmj.com/content/thoraxjnl/66/Suppl_2/ii1.full.pdf

British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011

The bacterial species Streptococcus pneumoniae consists of 90 immunologically distinct serotypes, of which some possess distinct epidemiological properties. Certain serotypes are much more likely to be associated with nasopharyngeal colonisation than to cause invasive disease. Compared with transient or infrequent colonisers, serotypes carried at high rates by young children may rapidly elicit age-associated natural immunity to invasive disease. Other serotypes seem to be of disproportionate importance as causes of disease in very young infants, in older children, in immunocompromised individuals, or in elderly people. Some serotypes seem to be associated with particular disease syndromes, such as complicated pneumonias in children, or with higher rates of hospitalisation in children or mortality in adults, or are consistently responsible for outbreaks in certain populations. Since pneumococcal conjugate vaccines are directed at specific serotypes, national immunisation advisory committees may wish to consider these serotype-specific properties when considering which vaccine formulation to introduce into a national programme.

https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(05)01280-6.pdf

Epidemiological differences among pneumococcal serotypes

“It seems probable that this study covers the period of practical extinction of empyema as an important disease.” Lionakis B et al , J Pediatr 1958. 

### 1.1 Structure of the guideline

The format follows that used for the BTS guidelines on the management of pleural disease in adults.1 At the start there is a summary table of the abstracted bullet points from each section. Following that is an algorithm summarising the management of pleural infection in children (fig 1). Each section starts with bulleted points of key recommendations using the revised SIGN grading system (table 1) available on http://www.sign.ac.uk/guidelines/fulltext/50/section6.html. Beneath each set of bullet points is a short paragraph detailing the referenced literature and the rationale behind the recommendations. The primary source literature has been individually graded for its methodology and the grading is given alongside each reference using the revised SIGN levels of evidence (table 2).

View this table:

 Table 1 
 Revised SIGN grading system: grades of recommendation



View this table:

 Table 2 
 Revised SIGN grading system: levels of evidence





 Figure 1 
 Algorithm for the management of pleural infection in children.



### 1.2 Methodology for generation of the guidelines

The initial literature search was carried out by the Library of the National Heart Lung Institute, Imperial College London. Further searches were then carried out by members of the working group who concentrated on their own topics. Details of the search strategy are given in Appendix 1.

Each section of the guideline was researched and drafted by a subgroup of the Paediatric Pleural Diseases Subcommittee (itself a subcommittee of the BTS Standards of Care Committee). Publications were rated according to the SIGN criteria for the calibre of the methodology of the research to give levels of evidence (table 2). Tables of evidence were then produced before writing the guideline sections using the SIGN grades of recommendations (table 1). Once all parts were merged into one document, the whole group then met to discuss …

https://thorax.bmj.com/content/thoraxjnl/60/suppl_1/i1.full.pdf

BTS guidelines for the management of pleural infection in children

Background. Little is known about the epidemiology of invasive pneumococcal disease (IPD) after the introduction of 7-valent pneumococcal conjugate vaccine (PCV7) in Spain and other European countries. Methods. We performed a 10-year prospective study including all children with culture-proven IPD admitted to Sant Joan de Deu Hospital, a children's center in the southern area of Barcelona, Catalonia, Spain. PCV7 was introduced in June 2001, and the current estimate of PCV7 coverage is 45%-50%. Results. Comparing the prevaccine period (1997-2001) with the vaccine period (2002-2006), among children aged <2 years, the rate of IPD increased from 32.4 episodes per 100,000 population to 51.3 episodes per 100,000 population (an increase of 58%; 95% confidence interval, 2%-145%), and among children aged 2-4 years, the rate increased from 11.3 episodes per 100,000 population to 26.5 episodes per 100,000 population (an increase of 135%; 95% confidence interval, 31%-320%). At clinical presentation, the rate of pneumonia and/or empyema among children aged <5 years increased from 3.6 episodes per 100,000 population to 15.1 episodes per 100,000 population (an increase of 320%; 95% confidence interval, 98%-790%). These increased rates of IPD were caused by non-PCV7 serotypes, which represented 38% and 72% of infecting serotypes in the prevaccine and vaccine periods, respectively (P<.001). Penicillin resistance decreased from 48% in the prevaccine period to 27% in the vaccine period (P =.005). In the vaccine period, there was an emergence of previously established virulent clones of non-PCV7 serotypes 1 and 5. There was also an increase in the prevalence of serotypes 19A and 6A expressed with different clonal types, including spain 23F -1 and Spain 6B -2. Conclusions. Since the introduction of PCV7 for children, there has been an emergence of IPD caused by virulent clones of non-PCV7 serotypes that has been associated with significant clinical changes and a decrease in antibiotic resistance.

Emergence of Invasive Pneumococcal Disease Caused by Nonvaccine Serotypes in the Era of 7-Valent Conjugate Vaccine

We investigated the increasing incidence of pediatric empyema during the 1990s at Primary Children’s Medical Center in Salt Lake City. Of 540 children hospitalized with community-acquired bacterial pneumonia (CAP) who were discharged from 1 July 1993 through 1 July 1999, 153 (28.3%) had empyema. The annual population incidence of empyema increased during the study period from 1 to 5 cases per 100,000 population aged !19 years. Streptococcus pneumoniae was identified as the most common cause of CAP with or without empyema; serotype 1 accounted for 50% of the cases of pneumococcal empyema. Patients with empyema were more likely to be13 years old, to have 7 days of fever, to have varicella, and to have received antibiotics and ibuprofen before admission to the hospital, compared with patients without empyema ( for each P ! .0001 factor). The increasing incidence of empyema was associated with infection due to S. pneumoniae serotype 1, outpatient treatment with certain antibiotics, ibuprofen use, and varicella.

Timothy A. Johnson

Papers

An Epidemiological Investigation of a Sustained High Rate of Pediatric Parapneumonic Empyema: Risk Factors and Microbiological Associations