Angkor Hospital for Children Faculty Development Course

Practice Guidelines

What is a Practice Guideline? A summary of recommended clinical practice for a specific condition together with the rationale and supporting evidence. May include a clinical algorithm What do they look like? Definitions of the condition (inclusions/exclusions) Etiology of the condition Evidence-based guidelines for: o Assessment: clinical, radiological, laboratory o Management: medications, therapies, admission criteria, follow-up Areas of future research References Why use Practice Guidelines? Quick access to the best practices in one location Less likely to make mistakes (human error is a major cause of morbidity, mortality and the inappropriate use of resources) Proven improved clinical outcomes Make our lives easier with standard orders Challenges in using them Not available at point of care Too simple, too ambiguous, poor evidence, dont match patient goals/values Inapplicability in local settings Out of date (because guidelines take too long to make) Some Websites for Practice Guidelines Guideline International Network http://www.g-i-n.net National Guideline Clearing House (US) http://www.guideline.gov National Institute for Health and Clinical Excellence (NICE-UK) http://www.nice.org.uk Some Articles Christakis DA, Rivara FP. Pediatricians awareness of and attitudes about four clinical practice guidelines. Pediatrics 1998;101:82530 Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998;317:85861 Fox J, Patkar V, Chronakis I, Begent R. From practice guidelines to clinical decision support: closing the loop. J R Soc Med 2009: 102: 464473 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005;330:765 Peterson ED, Roe MT, Mulgund J, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 2006;295:191220

Angkor Hospital for Children Faculty Development Course

Practice Guidelines

Selections from Community Acquired Pneumonia in children 60 days through 17 years of age July 2006
http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/evidence-based-guidelines

Target Population
Inclusions: Intended primarily for use in: children 60 days through 17 years of age acquired by exposure to organisms in the with signs, symptoms, or other findings suggesting community. uncomplicated pneumonia Exclusions: The guidelines do not address all considerations needed to manage those with: toxic appearance or requiring intensive care congenital, acquired, or drug induced persistence of a neonatal cardiac or pulmonary disorder immunocompromise recent hospitalization with exposure to nosocomial flora chronic conditions such as cystic fibrosis that likely aspiration of a foreign body or stomach contents uniquely alter pathophysiology and care options.

Introduction
This guideline revision presents new evidence concerning: etiology of community acquired pneumonia (CAP); a decline in the incidence of CAP due to S. pneumoniae as a result of the use of a heptavalent conjugated pneumococcal vaccine (PCV7, Prevnar); refined clinical measures for identification of children with pneumonia; treatment of presumed bacterial pneumonia due to the increased prevalence of strains of S. pneumoniae which are either intermediately or highly resistant to penicillin.

Etiology
Bacterial causes o Streptococcus pneumoniae accounted for 13% to 28% of CAP in children prior to the introduction of a heptavalent conjugated pneumococcal vaccine (PCV7, Prevnar) in 2000 (Overturf 2000 [S]). PCV7 has reduced overall invasive disease due to S. pneumoniae (Whitney 2003 [D]). Though current prevalence has not been studied, S. pneumoniae continues to be the most commonly identified bacterial cause of community acquired pneumonia in children (Heiskanen-Kosma 2003 [C]). o Group A Streptococcus, S. aureus, and H. influenzae cause pneumonias much less frequently (Korppi 1993 [C]). o Mycoplasma pneumoniae and Chlamydia (Chlamydophila) pneumoniae are more common in school-age children (Korppi 2004b [C]); these organisms may be becoming increasingly prevalent in preschool children (Esposito 2002 [C]). Viruses are identified most often in children < 5 years of age. Respiratory syncytial virus (RSV) is the most common viral etiology in children < 3 years of age. In younger age groups, Adenovirus, Parainfluenza virus, Influenza virus, and the recently discovered Human metapneumovirus have also been identified (Williams 2004 [C], Laundy 2003 [C], Murphy 1981 [C]). Mixed etiologies are reported in 30% to 50% of children with CAP (Korppi 2004b [C], Heiskanen-Kosma 2003 [C], Juven 2000 [C]).

Assessment and Diagnosis

Radiologic Assessment It is recommended, for children with clinical evidence of pneumonia, that chest X-rays be obtained when: o clinical findings are ambiguous, o a complication such as a pleural effusion is suspected, or o pneumonia is prolonged and unresponsive to antimicrobials (Swingler 1998 [A], Alario 1987 [C], Bachur 1999 [D]).

Medications age 5 years and older

It is recommended, for children age 5 years and older, that a macrolide be used to treat CAP. This treatment will cover M. pneumoniae and C. pneumoniae, the most common etiologies of CAP for children in this age group. A macrolide may also cover S. pneumoniae, the most common bacterial cause of CAP in all age groups. Treatment duration is 7 to 10 days, although a five-day course of azithromycin may be used (Wubbel 1999 [A], Harris 1998 [A], Klein 1997 [S,E]). It is recommended, in a child with a more severe case of CAP (see recommendation #3), that the combination of both a macrolide and a -lactam agent, (such as high dose amoxicillin or ceftriaxone) be considered. This will provide better coverage for resistant organisms and mixed infections (Korppi 2004b [C], Heiskanen-Kosma 2003 [C], Juven 2000 [C], Local Expert Consensus [E]).

Medications more severe disease

Angkor Hospital for Children Faculty Development Course

Practice Guidelines

Angkor Hospital for Children Faculty Development Course

Practice Guidelines

An admission order template for CAP (only for example) Admit to IPD Diagnosis: Community Acquired Pneumonia Condition: Stable Vitals every __ hrs. Pulse oximetry every ___ hrs. Activity: [ ] As tolerated [ ] Seated at bedside [ ] Bedrest Diet: [ ] Regular [ ] Liquid [ ] NPO Allergies: [ ] NKDA _________________________ IV: [ ] Saline lock Drugs: Antibiotic: [ ] Ceftriaxone 50-75mg/kg IV daily (max 2gms per day) for ___ days [ ] IV [ ] PO [ ] Azithromycin (age >5yo) 2-5th days 5mg/kg daily [ ] Paracetamol 10-15mg/kg every 4-6 hours as needed for fever/discomfort [ ] Albuterol 2.5mg neb every ___ 4hrs [ ] as needed for coughing/dyspnea Labs: [ ] Electrolytes [ ] CBC Sputum [ ] GS & culture [ ] AFB Studies: [ ] CXR Other: ______________________________________________ 1st day 10mg/kg daily [ ] Bolus ____________ [ ] IVF ____________@____ml/hr Oxygen: [ ] NC ____L/min [ ] Mask ____L/min adjust to keep O2 sat > 92%