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
University of California, San Diego1, University of Utah2, University of Pennsylvania3, Rhode Island Hospital4, Boston Children's Hospital5, Children's Mercy Hospital6, Baylor College of Medicine7, Cleveland Clinic8, University of Texas Southwestern Medical Center9, Centers for Disease Control and Prevention10, University of Missouri–Kansas City11, Emory University12
TL;DR: Eidenced-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.
Abstract: 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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TL;DR: The incidence of community-acquired pneumonia requiring hospitalization was highest among the oldest adults and despite current diagnostic tests, no pathogen was detected in the majority of patients.
Abstract: Background Incidence estimates of hospitalizations for community-acquired pneumonia among children in the United States that are based on prospective data collection are limited. Updated estimates of pneumonia that has been confirmed radiographically and with the use of current laboratory diagnostic tests are needed. Methods We conducted active population-based surveillance for community-acquired pneumonia requiring hospitalization among children younger than 18 years of age in three hospitals in Memphis, Nashville, and Salt Lake City. We excluded children with recent hospitalization or severe immunosuppression. Blood and respiratory specimens were systematically collected for pathogen detection with the use of multiple methods. Chest radiographs were reviewed independently by study radiologists. Results From January 2010 through June 2012, we enrolled 2638 of 3803 eligible children (69%), 2358 of whom (89%) had radiographic evidence of pneumonia. The median age of the children was 2 years (interquartile ...
2,088 citations
Centers for Disease Control and Prevention1, University of Utah2, University of California, San Francisco3, University of Minnesota4, Northeast Ohio Medical University5, Boston Children's Hospital6, University of Pennsylvania7, The Pew Charitable Trusts8, Brigham and Women's Hospital9, University of California, Davis10, Georgetown University Medical Center11, Harvard University12, Washington University in St. Louis13, University of Illinois at Chicago14, Pacific Lutheran University15
TL;DR: In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.
Abstract: Importance The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown. Objective To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States. Design, Setting, and Participants Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated. Exposures Ambulatory care visits. Main Outcomes and Measures Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population. Results Of the 184 032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions. Conclusions and Relevance In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.
1,162 citations
Additional excerpts
...Bronchitis or bronchiolitise 259 28 (18-39) 608 23 (18-28) 140 30 (20-40) 1007 25 (20-30)...
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...Other skin, cutaneous, and mucosal conditions 607 37 (30-43) 1321 32 (25-39) 384 64 (39-89) 2312 38 (30-45)...
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...Urinary tract infections 436 23 (17-28) 1465 35 (30-41) 459 64 (51-77) 2360 35 (31-40)...
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...Skin, cutaneous, and mucosal infections 570 39 (32-46) 1493 39 (33-44) 230 38 (29-47) 2293 39 (34-43)...
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...Pharyngitis 1001 91 (76-105) 785 29 (23-35) 39 d 1825 43 (38-49)...
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TL;DR: The present consensus statement summarizes current strategies on diagnosis, treatment, and prevention of 2019-nCoV infection in children and is based on the Novel Coronavirus Infection Pneumonia Diagnosis and Treatment Standards (the fourth edition) and other previous diagnosis and treatment strategies for pediatric virus infections.
Abstract: Since the outbreak of 2019 novel coronavirus infection (2019-nCoV) in Wuhan City, China, by January 30, 2020, a total of 9692 confirmed cases and 15,238 suspected cases have been reported around 31 provinces or cities in China. Among the confirmed cases, 1527 were severe cases, 171 had recovered and been discharged at home, and 213 died. And among these cases, a total of 28 children aged from 1 month to 17 years have been reported in China. For standardizing prevention and management of 2019-nCoV infections in children, we called up an experts’ committee to formulate this experts’ consensus statement. This statement is based on the Novel Coronavirus Infection Pneumonia Diagnosis and Treatment Standards (the fourth edition) (National Health Committee) and other previous diagnosis and treatment strategies for pediatric virus infections. The present consensus statement summarizes current strategies on diagnosis, treatment, and prevention of 2019-nCoV infection in children.
583 citations
TL;DR: Efforts to characterize antibiotic prescribing practices should focus on the South census region and family practitioners, and counties with a high proportion of obese persons, infants and children ≤ 2 years of age, prescribers per capita, and females were more likely to be high prescribing.
Abstract: Background. Appropriate antibiotic prescribing is an essential strategy to reduce the spread of antibiotic resistance. US prescribing practices have not been thoroughly characterized. We analyzed outpatient antibiotic prescribing data to identify where appropriate antibiotic prescribing interventions could have the most impact. Methods. Oral antibiotic prescriptions dispensed during 2011 were extracted from the IMS Health Xponent database. The number of prescriptions and census denominators were used to calculate prescribing rates. Prescription totals were calculated for each provider specialty. Regression modeling was used to examine the association between socioeconomic and population health factors and prescribing rates. Results. Healthcare providers prescribed 262.5 million courses of antibiotics in 2011(842 prescriptions per 1000 persons). Penicillins and macrolides were the most common antibiotic categories prescribed. The most commonly prescribed individual antibiotic agent was azithromycin. Family practitioners prescribed the most antibiotic courses (24%). The prescribing rate was higher in the South census region (931 prescriptions per 1000 persons) than in the West (647 prescriptions per 1000 persons; P 1.0). Conclusions. Efforts to characterize antibiotic prescribing practices should focus on the South census region and family practitioners. Further understanding of the factors leading to high prescribing among key target populations will inform appropriate prescribing interventions.
468 citations
Cites background from "The Management of Community-Acquire..."
...Guidelines for treatment of mild or moderate pediatric pneumonia in otherwise healthy children recommend amoxicillin as the first-line agent for school-aged children; macrolides are recommended only for school-aged children and adolescents with findings compatible with atypical pneumonia [31]....
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TL;DR: Repeated exposure to broad-spectrum antibiotics at ages 0 to 23 months is associated with early childhood obesity, and narrowing antibiotic selection is potentially a modifiable risk factor for childhood obesity.
Abstract: RESULTS Sixty-nine percent of children were exposed to antibiotics before age 24 months, with a mean (SD) of 23 (15) episodes per child Cumulative exposure to antibiotics was associated with later obesity (rate ratio [RR], 111; 95% CI, 102-121 for4 episodes); this effect was stronger for broad-spectrum antibiotics (RR, 116; 95% CI, 106-129) Early exposure to broad-spectrum antibiotics was also associated with obesity (RR, 111; 95% CI, 103-119 at 0-5 months of age and RR, 109; 95% CI, 104-114 at 6-11 months of age) but narrow-spectrum drugs were not at any age or frequency Steroid use, male sex, urban practice, public insurance, Hispanic ethnicity, and diagnosed asthma or wheezing were also predictors of obesity; common infectious diagnoses and antireflux medications were not
410 citations
References
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TL;DR: The advantages of the GRADE system are explored, which is increasingly being adopted by organisations worldwide and which is often praised for its high level of consistency.
Abstract: Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide
13,324 citations
"The Management of Community-Acquire..." refers methods in this paper
...As with all IDSA clinical practice guidelines initiated after 1 October 2008, the expert panel employed the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) method of assigning strength of recommendation and quality of the evidence to each recommendation (see Table 2) [3]....
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...The panel followed a process used in the development of other Infectious Diseases Society of America (IDSA) guidelines, which included a systematic weighting of the quality of the evidence and the grade of the recommendation [3] (Table 1)....
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Book•
01 Jan 1878
TL;DR: The Red River of the North basin of the Philippines was considered a part of the Louisiana Purchase by the United States Department of Commerce in the 1939 Census Atlas of the United Philippines as discussed by the authors.
Abstract: 1 Includes drainage basin of Red River of the North, not a part of any accession, but in the past sometimes considered a part of the Louisiana Purchase. i Includes Baker, Canton, Enderbury, Rowland, Jarvis, Johnston, and Midway Islands; and also certain other outlying islands (21 square miles). 3 Commonwealth of the Philippines, Commission of the Census; 1939 Census, Census Atlas of the Philippines. Source: Department of Commerce, Bureau of the Census.
10,650 citations
McMaster University1, Northwestern University2, University of Texas Health Science Center at San Antonio3, Johns Hopkins University4, University of Mississippi5, University of Utah6, LDS Hospital7, Centers for Disease Control and Prevention8, United States Department of Veterans Affairs9, Baylor College of Medicine10, Winthrop-University Hospital11, Stony Brook University12, University of Barcelona13
TL;DR: This work presents a meta-analyses of the immune system’s response to chronic obstructive pulmonary disease and shows clear patterns of decline in the immune systems of elderly patients with compromised immune systems.
Abstract: Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.
5,558 citations
"The Management of Community-Acquire..." refers background or methods in this paper
...Sputum Gram Stain and Culture Gram stain and culture of expectorated sputum are recommended for adults hospitalized with CAP [27]....
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...Therapy with the respiratory fluoroquinolones has demonstrated treatment outcomes for adults that are not inferior to macrolides and tetracyclines [27, 209]....
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...Process Overview As with other clinical practice guidelines developed by IDSA, a need for guidelines for pediatric CAP was demonstrated and the goals for the guidelines were similar to those for CAP in adults [27]....
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...diagnose pneumococcal pneumonia in adults [27]....
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TL;DR: A prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes and may help physicians make more rational decisions about hospitalization for patients with pneumonia.
Abstract: Background There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation. Methods From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate of > or = 30 or a temperature of > or = 40 degrees C), and abnormal laboratory findings (such as a pH or = 30 mg per deciliter [11 mmol per liter] or a sodium concentration Results There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P=0.22), from 0.6 to 0.7 percent for class II (P=0.67), and from 0.9 to 2.8 percent for class III (P=0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients. Conclusions The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia.
3,996 citations
TL;DR: A simple six point score based on confusion, urea, respiratory rate, blood pressure, and age can be used to stratify patients with CAP into different management groups.
Abstract: Background: In the assessment of severity in community acquired pneumonia (CAP), the modified British Thoracic Society (mBTS) rule identifies patients with severe pneumonia but not patients who might be suitable for home management. A multicentre study was conducted to derive and validate a practical severity assessment model for stratifying adults hospitalised with CAP into different management groups. Methods: Data from three prospective studies of CAP conducted in the UK, New Zealand, and the Netherlands were combined. A derivation cohort comprising 80% of the data was used to develop the model. Prognostic variables were identified using multiple logistic regression with 30 day mortality as the outcome measure. The final model was tested against the validation cohort. Results: 1068 patients were studied (mean age 64 years, 51.5% male, 30 day mortality 9%). Age ⩾65 years (OR 3.5, 95% CI 1.6 to 8.0) and albumin C onfusion, U rea >7 mmol/l, R espiratory rate ⩾30/min, low systolic( B lood pressure), age ⩾65 years (CURB-65 score) based on information available at initial hospital assessment, enabled patients to be stratified according to increasing risk of mortality: score 0, 0.7%; score 1, 3.2%; score 2, 3%; score 3, 17%; score 4, 41.5% and score 5, 57%. The validation cohort confirmed a similar pattern. Conclusions: A simple six point score based on confusion, urea, respiratory rate, blood pressure, and age can be used to stratify patients with CAP into different management groups.
2,576 citations