By Sam Spizman
Recently, CHOA put together a task force to review the evaluation and treatment of pneumonia. Members included representatives from both inpatient and outpatient care areas. The goal was to provide a more consistent and evidence-based approach to treatment. Based on their review, CHOA implemented a guideline for simple pneumonia in December 2014. The guidelines are available on the new MD portal. The key points are discussed below:
There are some exclusion criteria. The guideline excludes neonates and complex patients with comorbidities. Examples include:
- Infants <2 Months Of Age
- Cystic Fibrosis
- Nosocomially Acquired Pneumonia (>48 Hrs)
- Moderate To Severe Effusion, Empyema/Abscess, Necrosis
- Multilobar Pneumonia · Suspected Aspiration Pneumonia
- Medically Complex Patients
This last criterion is clinically subjective.
The admission criteria are listed as the following:
- Signs and Symptoms Of Respiratory Distress (note: pulse ox of 90% acceptable for outpatient management)
- Vomiting/poor PO/dehydration
- Inability To Manage Patient At Home
- Failed Outpatient Therapy
- Consider If ≤ 6 Months With Lobar Consolidation
These are not all inclusive and we welcome any phone conversation to better take care of your patient.
One of the main goals for the taskforce was to recommend antibiotic therapy for both outpatient and inpatient treatment. Literature reviews still show that the most common etiologic bacterial organism is pneumococcus (for simple lobar pneumonias without effusion or empyema). Staph aureus and Strep pyogenes are considerations, but are less prevalent.
Strep pneumoniae continues to show susceptibility to penicillins. Because of this, Amoxicillin is the recommended first-line antibiotic of choice. The recommended daily dosing is that of high-dose Amoxicillin (90-100mg/kg/day) as in the treatment of otitis media. It is recommended to divide this into 3 doses, not 2. The literature to support this says that the required MIC (mean inhibitory concentration) for pneumococcus is 2mcg/ml. While both bid and tid dosing achieve adequate peaks, bid dosing achieves only a 65% cure rate while tid dosing achieves a 90% cure rate. The implication is that bid dosing results in the MIC falling below 2mcg/ml in some patients, resulting in treatment failures.
For inpatients, recommended IV therapy is Ampicillin until the patient meets discharge criteria.
In the case of true penicillin allergy, the recommended treatment is clindamycin for outpatients and ceftriaxone or levofloxacin for inpatients.
Lastly, treatment to cover atypical pneumonia (Mycoplasma) is not recommended unless the patient is failing outpatient therapy.
Take- home points:
– Amoxicillin and Ampicillin are the first-line recommendations for simple CAP
– High-dose Amoxicillin should be divided into tid dosing
– We all probably utilize too much Rocephin and Augmentin for CAP
Please refer to CHOA MD portal: md.choa.org to review this and other CHOA Guidelines