Mabama Doctors’ Hospital No. Med. Serv. Doc.

2019- 001

Title: Page: 1 of

CLINICAL PATHWAYS Effective Date March ,2019

GUIDELINES Retires Policy Dated: None
PNEUMONIA – COMMUNITY- Previous Versions Date None
ACQUIUED
Approval Date: March , 2019

Pneumonia – Community-Acquired

1
Patient presents w/ probable
community-acquired pneumonia

2
DIAGNOSIS Is
CAP highly NOO
suspected?
ALTERNATIVE
DIAGNOSIS

YES

3
SEVERITY ASSESSMENT

CLINICAL
DECISION Should
NO patient be admitted to YES
hospital?

HOSPITAL
ADMISSION See
next page for
treatment.
 Mabama Doctors’ Hospital No. Med. Serv. Doc. 2019- 001

Title: Page: 2 of

CLINICAL PATHWAYS Effective Date March ,2019

GUIDELINES Retires Policy Dated: None
PNEUMONIA – COMMUNITY- Previous Versions Date None
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Approval Date: March , 2019

4
A. Supportive therapy
B. Pharmacology therapy
Patient’s Age Empiric therapy for the probable cause of CAP (oral)
Bacteria Atypical Bacteria Influenza
Amoxicillin Azithromycin Oseltamivir
Alternative: Alternatives:
<5 yrs old
- Co-amoxiclav - Clarithromycin
- Erythromycin

>_ 5 yrs old Amoxicilin +_ Azithromycin Oseltamivir

macrolide ₁ Alternatives: Zanamivir ₂
Alternatives: - Clarithromycin
-Co-amoxiclav - Erythromycin
- Doxycycline2

₁ For children w/ probable bacterial CAP w/ no clinical, laboratory, or radiographic evidence that differentiates
bacterial CAP from atypical CAP C
₂ For children > 7 yrs old Follow-up at 48-72
Modified from; Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in hours See next
infants and children older than 3 months of age; clinical practice guideline by the Pediatic Infectious Diseases Society page
and the Infectious Diseases Societybof America, Clin Infect Dis. 2011;53(7):e10
 Mabama Doctors’ Hospital No. Med. Serv. Doc. 2019- 001

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CLINICAL PATHWAYS Effective Date March ,2019

GUIDELINES Retires Policy Dated: None
PNEUMONIA – COMMUNITY- Previous Versions Date None
ACQUIUED
Approval Date: March , 2019

FOLLOW-UP OF OUTPATIENTS W/ CAP

2 Diagnosis
 Confirm diagnosis
 Asses possible
ADVICE THE Did patient complication
CAREGIVER improve? A Supportive therapy
YES NO
 Complete the B Pharmacological therapy
antibiotic regimen
 Adjust/shift antibiotic, if
E Prevention necessary
- See page 8

MANAGEMENT OF HOPITALIZED PATIENT

A. Supportive therapy
B. Pharmacological therapy
Patient’s Immunizaton Empiric therapy for the probable cause of CAP
Status & Local
Penicilin Resistance Bacteria Atypical Bacteria Influenza
Pattern
Ampicillin Azithromycin + Oseltamivir
 Complete vaccine Penicillin G β -lactam₂ Zanamivir₃
 Minimal local Alternatives: Alternatives:
Penicillin resistance - Ceftriaxone - Clarithromycin
- Cefotaxime - Erythromycin
- Plus either:₁ - Doxyxycline₃
-Vancomycin
- Levofloxacin₄
- Clindamycin

Incomplete vaccine Ceftriaxone Azithromycin+ Oseltamivir

Cefotaxime B-lactam2 Zanamivir3
Significant local
- Plus either:1 Alternatives:
penicillin
- Vancomycin - Clarithrom
resistance
- Clindamycin - Erythromycin
Alternative: - Doxyxycline3
- Levofloxacin - Levofloxacin4
- Plus either:1
- Vancomycin
- Clindamycin
 Mabama Doctors’ Hospital No. Med. Serv. Doc. 2019- 001

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CLINICAL PATHWAYS Effective Date March ,2019

GUIDELINES Retires Policy Dated: None
PNEUMONIA – COMMUNITY- Previous Versions Date None
ACQUIUED
Approval Date: March , 2019

C
Follow-up at 48-
72 hours

FOLLOW-UP OF INPATIENTS W/ CAP

Discharge 2 Diagnosis
 Asses patient for possible  Asses possible complication
discharge A Supportive therapy
Did Patient
Advise the caregiver
Improve? B Pharmacological therapy
 Complete the antibiotic YES NOOO
regimen  Adjust/Shift antibiotic, if
E Prevention necessary
 See page 8 D Specialist referral
 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 No. Med. Serv. Doc. 2019- 001

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CLINICAL PATHWAYS Effective Date March ,2019

GUIDELINES Retires Policy Dated: None
PNEUMONIA – COMMUNITY- Previous Versions Date None
ACQUIUED
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 No. Med. Serv. Doc. 2019- 001

Title: Page: 6 of

CLINICAL PATHWAYS Effective Date March ,2019

GUIDELINES Retires Policy Dated: None
PNEUMONIA – COMMUNITY- Previous Versions Date None
ACQUIUED
Approval Date: March , 2019
 Mabama Doctors’ Hospital No. Med. Serv. Doc. 2019- 001

Title: Page: 7 of

CLINICAL PATHWAYS Effective Date March ,2019

GUIDELINES Retires Policy Dated: None
PNEUMONIA – COMMUNITY- Previous Versions Date None
ACQUIUED
Approval Date: March , 2019