PCAP GUIDELINES

Etiology
Outpatient and in-patients: bacterial > viral For bacterial: Streptoccocus pneumoniae> H. influenzae> Mycoplasma sp.> Chlamydia sp.

Risk Classification
Variables Co-morbids Compliant Caregiver Ability to Follow up Dehydration Feeding Age RR 2-12 mos 1-5 yrs > 5 yrs PCAP A Minimal None + + None Yes > 11 months > Or = 50 > Or = 40 > Or = 30 PCAP B Low + + + Mild Yes > 11 months > 50 > 40 > 30 PCAP C Moderate + None None Moderate No < 11 months > 60 > 50 > 35 PCAP D High + None None Severe No < 11 months > 70 > 50 > 35

Variables Retractions Head bobbing Cyanosis Grunting Apnea Sensorium

PCAP A Minimal

PCAP B Low

PCAP C Moderate Intercostal/ subcostal + +

PCAP D High Supraclavicular + + + +

Awake

Awake

Irritable

Lethargic/ stuporous/ comatose + Admit to ICU Refer to specialist

Complications Action OPD Follow up at end of treatment OPD Follow up after 3 days

+ Admit to wards

Diagnostics
No diagnostic aids initially requested for PCAP A or B managed on an outpatient basis Routine exams for PCAP C or D:
CXR PAL WBC count CS: blood (for PCAP D), pleural fluid, ETA upon intubation Blood gas/O2 sat

Diagnostics
Sputum CS for older children ESR and CRP are not routinely requested

Predictors of bacterial pathogen

Clinical prediction using a bacterial pneumonia score
BPS 4 ~ (+) bacterial pathogen in hospitalized patients 1 month 5 years

Probable organisms acc. to age

Increase age, higher chance of bacterial pathogen, increasing frequency of atypical organism

Decreased breath sounds

Treatment
Antibiotics are recommended in:
1. Patients classified as either PCAP A or B and is: (a) beyond 2 years of age; or (b) having high grade fever without wheeze 2. Patients classified as PCAP C and is: (a) beyond 2 years of age; (b)having high grade fever without wheeze; (c) having alveolar consolidation in chest x-ray; (d) or having WBC count > 15,000 3. Patients classified as PCAP D

Treatment
Empiric treatment (bacterial etiology):
PCAP A or B w/o previous antibiotic: Amoxicillin 45 mg/kg/day in 3 divided doses x 3 days (min)
Macrolide if w/ hypersensitivity of amoxicillin Other regimens: Co-trimoxazole, azithromycin, erythromycin, co-amoxiclav, clarithromycin

PCAP C w/o previous antibiotic and has complete immunization against Hib: Penicillin G 100,000 u/kg/day
Oral amoxicillin in patients who can tolerate feeding (comparable to parenteral penicillin)

Treatment
Empiric treatment (bacterial etiology):
PCAP C w/o Hib immunization: IV ampicillin 100 mg/kg/day in 4 divided doses
Monotherapy (parenteral ampicillin) or combination therapy (IV penicillin + chloramphenicol) in patients who cannot tolerate feeding Other regimens: Amoxicillin/sulbactam, cefuroxime, chloramphenicol

PCAP D: consult a specialist

Treatment
If CA-MRSA suspected, refer immediately to the appropriate specalist. Strategies in clinical management of MRSA:
Follow antibiotic susceptibility based on culture studies Vancomycin remains to be the 1st line therapy for severe infections possibly caused by MRSA CA-MRSA were more likely to be synergistically inhibited by vancomycin + gentamicin vs. vancomycin alone

Treatment
Initial treatment (viral etiology):
Ancillary treatment Oseltamivir 2 mg/kg/dose BID x 5 days may be given for laboratory confirmed influenza

Response to antibiotics
Decrease in respiratory signs (i.e. tachypnea) and defervescense within 72 hours after initiation of antibiotic FAVORABLE
Nonsevere: RR>5 bpm slower than baseline Severe: defervescense, decrease in tacypnea & chest indrawing, increase in O2 sat & ability to feed within 48 hours

Persistence of symptoms beyond 72 hours after initiation of antibiotics RE-EVALUATE

Response to antibiotics
Improved: RR < age-specific range without chest indrawing or any danger signs (central cyanosis, inability to drink, abnormally sleepy or convulsions) Treatment failure
Same: RR > age-specific range WITHOUT chest indrawing or any danger signs Worse: Developed chest indrawing or any of the danger signs

Response to antibiotics
If a patient w/ PCAP A or B is not responding to antibiotics w/in 72 hours, consider:
Change the initial antibiotic; or Start an oral macrolide; or Re-evaluate diagnosis

Causes of treatment failure: co-infection w/ RSV, non-adherence to treatment

Response to antibiotics
If a patient w/ PCAP C is not responding to antibiotics w/in 72 hours, consider:
Penicillin resistant Strep pneumoniae; or Presence of pulmonary or extrapulmonary complications; or Other diagnosis

Causes of treatment failure: antibiotic resistance, clinical sepsis, progressive pneumonia, mixed infection

Response to antibiotics
If a patient w/ PCAP D is not responding to antibiotics w/in 72 hours, consider:
Immediate re-consultation w/ a specialist

Response to antibiotics
Switch from IV to oral 2-3 days after initiation of antibiotics recommended if:
Responding to the initial antibiotic therapy Able to feed w/ intact GI absorption Without pulmonary or extrapulmonary complications

Switch from 3 days of IV ampicillin to 4 days of amoxicillin (preferred) or cotrimoxazole

Ancillary treatment
Oxygen and hydration if needed among inpatients Cough preparations, chest physiotherapy, pNSS nebulization, steam inhalation, topical solution, bronchodilators are not routinely used A bronchodilator may be used if with wheezing

Prevention
Pneumococcal and Hib vaccination Zinc supplementation may be administered to prevent pneumonia Handwashing using antibacterial soaps Breastfeeding