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Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 1 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
Pneumonia – Community-Acquired 1 Patient presents w/ probable community-acquired pneumonia
2 DIAGNOSIS Is CAP highly suspected?
NOO ALTERNATIVE DIAGNOSIS
YES
3 SEVERITY ASSESSMENT
NO
CLINICAL DECISION Should patient be admitted to hospital?
YES
HOSPITAL ADMISSION See next page for treatment.
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 2 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
4 A. Supportive therapy B. Pharmacology therapy Patient’s Age Empiric therapy for the probable cause of CAP (oral) Bacteria <5 yrs old
>_ 5 yrs old
Atypical Bacteria
Influenza
Amoxicillin Alternative: - Co-amoxiclav
Azithromycin Alternatives: - Clarithromycin - Erythromycin
Oseltamivir
Amoxicilin +_ macrolide ₁ Alternatives: -Co-amoxiclav
Azithromycin Alternatives: - Clarithromycin - Erythromycin - Doxycycline2
Oseltamivir Zanamivir ₂
₁ For children w/ probable bacterial CAP w/ no clinical, laboratory, or radiographic evidence that differentiates bacterial CAP from atypical CAP ₂ For children > 7 yrs old Modified from; Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age; clinical practice guideline by the Pediatic Infectious Diseases Society and the Infectious Diseases Societybof America, Clin Infect Dis. 2011;53(7):e10
C Follow-up at 48-72 hours See next
page
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 3 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
FOLLOW-UP OF OUTPATIENTS W/ CAP
Diagnosis
2
ADVICE THE CAREGIVER
YES
Did patient improve?
A Supportive therapy
NO
B Pharmacological therapy
Complete the antibiotic regimen
E Prevention -
Confirm diagnosis Asses possible complication
Adjust/shift antibiotic, if necessary
See page 8
MANAGEMENT OF HOPITALIZED PATIENT A. Supportive therapy B. Pharmacological therapy Patient’s Immunizaton Status & Local Penicilin Resistance Pattern
Complete vaccine Minimal local Penicillin resistance
Incomplete vaccine Significant local penicillin resistance
Empiric therapy for the probable cause of CAP Bacteria
Atypical Bacteria
Ampicillin Penicillin G Alternatives: - Ceftriaxone - Cefotaxime - Plus either:₁ -Vancomycin - Clindamycin
Azithromycin + β -lactam₂ Alternatives: - Clarithromycin - Erythromycin - Doxyxycline₃ - Levofloxacin₄
Ceftriaxone Cefotaxime - Plus either:1 - Vancomycin - Clindamycin Alternative: - Levofloxacin - Plus either:1 - Vancomycin - Clindamycin
Azithromycin+ B-lactam2 Alternatives: - Clarithrom - Erythromycin - Doxyxycline3 - Levofloxacin4
Influenza Oseltamivir Zanamivir₃
Oseltamivir Zanamivir3
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 4 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
C Follow-up at 4872 hours
FOLLOW-UP OF INPATIENTS W/ CAP
Discharge
2 Diagnosis
Asses patient for possible discharge
Advise the caregiver
Complete the antibiotic regimen
YES
Did Patient Improve?
NOOO
E Prevention
Asses possible complication
A Supportive therapy B Pharmacological therapy
Adjust/Shift antibiotic, if necessary
D Specialist referral
See page 8
If indicated
1 COMMUNITY-ACQUIRED PNEUMONIA
A previously healthy child presntimg with signs and symptoms of lower respiratory tract infection, acquired outside at the hospital. The most common bacterial cause of childhood pneumonia is Streptococcus pmeumoniae - Usually causes about 1/3 of radiographically-confirmed pneumonia oin children <2 years of age - Pneumonia secondary to group A Streptococcus & Staphylococcus aureus are more frequently associated w/ empyema or pdiactric ICU admission Viruses commonly affects children <1 year of age than those aged >2 years; respiratory syncytial viruses (RSV) being the most frequently detected virus - Adenoviruses, bocaviruses, human metapneumovirus, influenza A&B viruses, parainfluenza viruses, coronaviruses & rhinovirus are less frequently identified Mixed infection may occur in 8-40% of CAP cases
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 5 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
2 DIAGNOSIS
Diagnosis of CAP is primarily based on history and physical findings (eg signs and symptoms of respiratory distress fever) - Lab and radiographic exams may aid in the diagnosis pf severe cases or in patietns who failed to show clinical improvement after inflation of antibiotic therapy.
HISTORY
Patient’s age, Immunization status - Age is a good predictor of causative agent Viruses are often linked in up to 50% of pneumonia in young children S pneumonia followed by atypical pneumonia (eg Mycoplasma and Chlamydia) is the most likely pathogen in older children with pneumonia of bacterial origin - Immunization status is important because children fully immunized against Haemophilisz influenzae type B & S pneumoniae are less likely to be infected with these pathogens Symptoms may include fever, dyspnea, cough, chest or abdominal pain with or without vomiting, headache - Patients w/ cough or difficulty of breathing w/ either lower chest indrawing, nasal flaring, or grunting are considered to have severe pneumonia - Patients w/ cough or difficulty of breathing w/ either cyanosis, severe respiratory distress, inability to drink or vomits everything, or lethargy, unconsciousness, convulsions have very severe pneumonia Should also take note of the season of the year; daycare attendance, exposure to tobacco smoke or infectious diseases (eg tuberculosis), history of travel, or coexisting of illness (ie cardiac or pulmonary disorders, immunodeficiencies, neuromuscular diseases)
Physical Exam
Combination of clinical findings are more predictive in diagnosing CAP Check for Temperature - Fever in viral pneumonia is generally lower than in bacterial pneumonia
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 6 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 7 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
No. Page:
Med. Serv. Doc. 2019- 001 1 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
Pneumonia – Community-Acquired 1 Patient presents w/ probable community-acquired pneumonia
2 DIAGNOSIS Is CAP highly suspected?
NOO ALTERNATIVE DIAGNOSIS
YES
3 SEVERITY ASSESSMENT
NO
CLINICAL DECISION Should patient be admitted to hospital?
YES
HOSPITAL ADMISSION See next page for treatment.
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 2 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
4 A. Supportive therapy B. Pharmacology therapy Patient’s Age Empiric therapy for the probable cause of CAP (oral) Bacteria <5 yrs old
>_ 5 yrs old
Atypical Bacteria
Influenza
Amoxicillin Alternative: - Co-amoxiclav
Azithromycin Alternatives: - Clarithromycin - Erythromycin
Oseltamivir
Amoxicilin +_ macrolide ₁ Alternatives: -Co-amoxiclav
Azithromycin Alternatives: - Clarithromycin - Erythromycin - Doxycycline2
Oseltamivir Zanamivir ₂
₁ For children w/ probable bacterial CAP w/ no clinical, laboratory, or radiographic evidence that differentiates bacterial CAP from atypical CAP ₂ For children > 7 yrs old Modified from; Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age; clinical practice guideline by the Pediatic Infectious Diseases Society and the Infectious Diseases Societybof America, Clin Infect Dis. 2011;53(7):e10
C Follow-up at 48-72 hours See next
page
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 3 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
FOLLOW-UP OF OUTPATIENTS W/ CAP
Diagnosis
2
ADVICE THE CAREGIVER
YES
Did patient improve?
A Supportive therapy
NO
B Pharmacological therapy
Complete the antibiotic regimen
E Prevention -
Confirm diagnosis Asses possible complication
Adjust/shift antibiotic, if necessary
See page 8
MANAGEMENT OF HOPITALIZED PATIENT A. Supportive therapy B. Pharmacological therapy Patient’s Immunizaton Status & Local Penicilin Resistance Pattern
Complete vaccine Minimal local Penicillin resistance
Incomplete vaccine Significant local penicillin resistance
Empiric therapy for the probable cause of CAP Bacteria
Atypical Bacteria
Ampicillin Penicillin G Alternatives: - Ceftriaxone - Cefotaxime - Plus either:₁ -Vancomycin - Clindamycin
Azithromycin + β -lactam₂ Alternatives: - Clarithromycin - Erythromycin - Doxyxycline₃ - Levofloxacin₄
Ceftriaxone Cefotaxime - Plus either:1 - Vancomycin - Clindamycin Alternative: - Levofloxacin - Plus either:1 - Vancomycin - Clindamycin
Azithromycin+ B-lactam2 Alternatives: - Clarithrom - Erythromycin - Doxyxycline3 - Levofloxacin4
Influenza Oseltamivir Zanamivir₃
Oseltamivir Zanamivir3
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 4 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
C Follow-up at 4872 hours
FOLLOW-UP OF INPATIENTS W/ CAP
Discharge
2 Diagnosis
Asses patient for possible discharge
Advise the caregiver
Complete the antibiotic regimen
YES
Did Patient Improve?
NOOO
E Prevention
Asses possible complication
A Supportive therapy B Pharmacological therapy
Adjust/Shift antibiotic, if necessary
D Specialist referral
See page 8
If indicated
1 COMMUNITY-ACQUIRED PNEUMONIA
A previously healthy child presntimg with signs and symptoms of lower respiratory tract infection, acquired outside at the hospital. The most common bacterial cause of childhood pneumonia is Streptococcus pmeumoniae - Usually causes about 1/3 of radiographically-confirmed pneumonia oin children <2 years of age - Pneumonia secondary to group A Streptococcus & Staphylococcus aureus are more frequently associated w/ empyema or pdiactric ICU admission Viruses commonly affects children <1 year of age than those aged >2 years; respiratory syncytial viruses (RSV) being the most frequently detected virus - Adenoviruses, bocaviruses, human metapneumovirus, influenza A&B viruses, parainfluenza viruses, coronaviruses & rhinovirus are less frequently identified Mixed infection may occur in 8-40% of CAP cases
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 5 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
2 DIAGNOSIS
Diagnosis of CAP is primarily based on history and physical findings (eg signs and symptoms of respiratory distress fever) - Lab and radiographic exams may aid in the diagnosis pf severe cases or in patietns who failed to show clinical improvement after inflation of antibiotic therapy.
HISTORY
Patient’s age, Immunization status - Age is a good predictor of causative agent Viruses are often linked in up to 50% of pneumonia in young children S pneumonia followed by atypical pneumonia (eg Mycoplasma and Chlamydia) is the most likely pathogen in older children with pneumonia of bacterial origin - Immunization status is important because children fully immunized against Haemophilisz influenzae type B & S pneumoniae are less likely to be infected with these pathogens Symptoms may include fever, dyspnea, cough, chest or abdominal pain with or without vomiting, headache - Patients w/ cough or difficulty of breathing w/ either lower chest indrawing, nasal flaring, or grunting are considered to have severe pneumonia - Patients w/ cough or difficulty of breathing w/ either cyanosis, severe respiratory distress, inability to drink or vomits everything, or lethargy, unconsciousness, convulsions have very severe pneumonia Should also take note of the season of the year; daycare attendance, exposure to tobacco smoke or infectious diseases (eg tuberculosis), history of travel, or coexisting of illness (ie cardiac or pulmonary disorders, immunodeficiencies, neuromuscular diseases)
Physical Exam
Combination of clinical findings are more predictive in diagnosing CAP Check for Temperature - Fever in viral pneumonia is generally lower than in bacterial pneumonia
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 6 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
Mabama Doctors’ Hospital Title: CLINICAL PATHWAYS GUIDELINES PNEUMONIA – COMMUNITYACQUIUED
No. Page:
Med. Serv. Doc. 2019- 001 7 of
Effective Date Retires Policy Dated: Previous Versions Date
March ,2019 None None
Approval Date:
March , 2019
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