Management Of Community-acquired Pneumonia Research Articles

Guidelines for the management of community-acquired pneumonia in children (2024 revision)

Guidelines for the management of community-acquired pneumonia in children (2024 revision)

Outcome of Empirical Antibiotic Prescription for the Treatment of Community Acquired Pneumonia

Background: The primary cause of illness and death in Bangladesh is community acquired pneumonia (CAP). Many hospitals in Bangladesh lack the resources to perform sputum cultures and sensitivity tests, making it difficult to identify the etiological agent of an infection. As a result, antibiotics are prescribed on a "empirical basis" rather than as part of a specific anti microbial treatment. The optimal antibiotic for treating CAP should be chosen using an empirical approach. Objective: The purpose of this study is to evaluate the effectiveness of various empirical antibiotic choices in the management of CAP. Methods: Eighty-two patients with CAP were included in this prospective observational research at a tertiary medical college hospital in Bangladesh. Inclusion and exclusion criteria were used to choose patients. Chest x-rays confirmed the diagnosis of CAP. The antibiotic was chosen based on clinical experience, which is an empirical method. The majority of patients received a combination antibiotic, whereas the remaining handful received monotherapy. The result served as an evaluation of the empiricism used in selecting the antibiotic. During the research, data were recorded in standardized formats. SPSS was used for the statistical analysis. Results: A total of 82 people were treated, and of them, 62 (or 76%) were men and 20 (or 24%) were women. The average age was 54.4% (9.6%). The round of antibiotics was supposed to last for a week. There were no unwanted medication reactions. No cases of lung abscess or parenchymal damage to the lungs occurred, and only one patient had paraneumonic effusion. Every single person made a full recovery. Conclusion: In many hospitals in Bangladesh, the choice of antibiotic for treating CAP is made on a "empirical" basis. Selecting an appropriate antibiotic requires better sputum culture and sensitivity testing in hospital labs.

Purulent pericarditis and cardiac tamponade in HIV: a case report on a dreaded complication of streptococcus pneumoniae

Introduction and importance: Purulent pericarditis is an uncommon complication of Streptococcus pneumoniae, which commonly occurs in an immunocompromised state such as HIV and can lead to life-threatening complications such as cardiac tamponade and potentially death if untreated. Early identification, pericardiocentesis, and general measures such as antibiotics and anti-inflammatory medications can be life-saving. Case presentation: We present a case of a 64-year-old male with HIV who presented with clinical symptoms suggestive of pericarditis. Chest imaging revealed multifocal airspace diseases and moderate pericardial effusion. He had worsening lactic acidosis, and bedside point-of-care ultrasound showed pericardial effusion with features suggestive of cardiac tamponade. His lactic acidosis improved with emergency pericardiocentesis. Blood and pericardial fluid cultures revealed Streptococcus pneumoniae. He was further treated with intravenous antibiotics, colchicine, and ibuprofen. Clinical discussion: Although Streptococcus pneumoniae is a common etiology of community-acquired pneumonia (CAP), it has not been cited as the leading cause of pericarditis or pericardial effusion. In immunocompromised patients, it is necessary to consider a broad differential diagnosis as an etiology of acute chest pain, as it may be challenging to differentiate pleuritic and pericarditic chest pain from clinical presentation only. Moreover, infectious etiology of acute pericarditis and pericardial effusion should be considered in this patient population, especially those with HIV. At the same time, it is crucial to promptly identify and treat cardiac tamponade to prevent further deterioration. Conclusion: Our case provides insight into the diagnosis and management of CAP and its potential complication of purulent pericarditis and cardiac tamponade in immunocompromised patients.

Combating paediatric pneumonia: the dynamic duo of cinnamon-clove steam and physiotherapy

IntroductionPaediatric community-acquired pneumonia (CAP) is a prevailing respiratory infection that impacts children in non-medical settings, giving rise to substantial morbidity and mortality, especially in less developed areas. The current study was aimed at finding a holistic approach for improving the management and treatment of paediatric CAP. For that purpose, a comparative interventional study was conducted to investigate the effectiveness of chest physiotherapy (CPT) combining with Cinnamon varum and Syzygium aromaticum steam therapy in paediatric CAP. MethodsA total of 60 paediatric patient hospitalised with CAP were assessed. The study included both male and female participants aged between three and 14 years. The study was conducted at Children Hospital and Institute of Child Health in Faisalabad, Pakistan. The subjects were divided into three equal groups: group 1 received CPT, group 2 underwent CPT accompanied with nebulization, and group 3 received CPT along with steam therapy using C. varum and S. aromaticum. Each participant received the assigned therapy twice a day for seven consecutive days. The study was approved and registered by Ethics Review Committee, Government College University, Faisalabad, Pakistan (Reference number GCUF/ERC/214). ResultsAmong the three groups studied, those who received the combined therapy exhibited improved outcome by improving the complete blood count (CBC), spirometer index, arterial blood gases (ABGs) and Systolic blood pressure, Multilobar infiltrates, Albumin, Respiratory rate, Tachycardia, Confusion, Oxygen and pH severity score for pneumonia. ConclusionsThe antimicrobial, anti-inflammatory and mucolytic properties of cinnamon and clove, along with the positive effects of CPT, resulted in reduced lung inflammation, enhanced respiratory performance, and improved vital signs.

The management of community-acquired pneumonia in adults at a rural regional hospital in KwaZulu Natal

BackgroundPneumonia stands as a significant global contributor to mortality, particularly in South Africa, where it ranks as the second leading cause of death. The country’s high prevalence of HIV infection compounds this issue, significantly increasing mortality rates associated with community-acquired pneumonia (CAP).ObjectiveThis study aimed to audit CAP patient management at a regional rural hospital in KwaZulu-Natal.MethodA retrospective review of patient files from September to December 2016 was undertaken. Data extraction from clinical files, conducted according to inclusion criteria, was transferred to a data collection sheet and analyzed using SPSS version 21.ResultsThe review encompassed 124 patient files over four months, revealing that 117 (94.4%) patients were not managed by the Standard Treatment Guidelines and Essential Medicines List for South Africa. Of the patients admitted with CAP, 54% were HIV positive, and 49 (39.5%) patients succumbed to the illness. Notably, none of the patients underwent assessment using a severity score.ConclusionThe findings underscore a need for more adherence to South African guidelines for managing CAP among staff at the rural regional hospital. This leads to severe consequences, exemplified by the high mortality rate. Urgent intervention is required to incorporate severity assessment scores into pneumonia evaluations, thus enabling appropriate clinical management.ContributionThis study sheds light on the significant impact of CAP within the South African hospital context, delineating critical gaps in clinical care and emphasizing the imperative to address clinical inertia.

Reassessing Halm's clinical stability criteria in community-acquired pneumonia management.

Halm's clinical stability criteria have long guided antibiotic treatment and hospital discharge decisions for patients hospitalised with community-acquired pneumonia (CAP). Originally introduced in 1998, these criteria were established based on a relatively small and select patient population. Consequently, our study aims to reassess their applicability in management of CAP in a contemporary real-world setting. This cohort study included 2918 immunocompetent patients hospitalised with CAP from three hospitals in Denmark between 2017-2020. The primary outcome was time to achieve clinical stability as defined by Halm's criteria. Additionally, we examined recurrence of clinical instability and severe complications. Cumulative incidence function or Kaplan-Meier survival curves were used to analyse these outcomes, considering competing risks. The study population primarily comprised elderly individuals (median age: 75 years) with significant comorbidities. The median time to clinical stability according to Halm's criteria was 4 days, with one-fifth experiencing recurrence of instability after early clinical response (stability within 3 days). Severe complications within 30 days mainly comprised mortality, with rates of 5.1% (64/1257) overall in those with early clinical response, 1.7% (18/1045) in the subgroup without do-not-resuscitate orders, and 17.3% (276/1595) among the rest. Halm's clinical stability criteria effectively classify CAP patients with different disease courses, yet achieving stability required more time in this aging population with substantial comorbidities and more severe disease. Early clinical response indicates reduced risk of complications, especially in those without do-not-resuscitate orders.

Impact of respiratory pathogens detection by a rapid multiplex polymerase chain reaction assay on the management of community-acquired pneumonia for children at the paediatric emergency department. A randomized controlled trial, the Optimization of Pneumonia Acute Care (OPTIPAC) study

ObjectivesThe pathogen of community-acquired pneumonia (CAP) in children is typically uncertain during initial treatment, leading to systematic empiric antibiotic use. This study investigates if having rapid multiplex PCR results in the emergency department (ED) improves empiric treatment. MethodsOPTIPAC, a French multicentre study (2016–2018), enrolled patients consulting for CAP at the paediatric ED in 11 centres. Patients were randomized to either receive a multiplex PCR test plus usual care or usual care alone and followed for 15 days. The primary outcome was the appropriateness of initial antimicrobial management, determined by a blinded committee. ResultsOf the 499 randomized patients, 248 were tested with the multiplex PCR. Appropriateness of the antibiotic treatment was higher in the PCR group (168/245, 68.6% vs. 120/249, 48.2%; Relative risk 1.42 [1.22–1.66]; p < 0.0001), chiefly by reducing unnecessary antibiotics in viral pneumonia (RR 3.29 [2.20–4.90]). No adverse events were identified. DiscussionThe multiplex PCR assay result at the ED improves paediatric CAP's antimicrobial stewardship, by both reducing antibiotic prescriptions and enhancing treatment appropriateness.

Incidence of drug-resistant pathogens in community-acquired pneumonia at a safety net hospital.

The 2019 Infectious Diseases Society of America guideline for the management of community-acquired pneumonia (CAP) emphasizes the need for clinician to understand local epidemiological data to guide selection of appropriate treatment. Currently, the local distribution of causative pathogens and their associated resistance patterns in CAP is unknown. A retrospective observational study was performed of patients admitted to an 870-bed safety net hospital between March 2016 and March 2021 who received a diagnosis of CAP or healthcare-associated pneumonia within the first 48 hours of admission. The primary outcome was the incidence of CAP caused by methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa (PsA) as determined by comparing the number of satisfactory sputum cultures or blood cultures with these drug-resistant organisms to the total number of reviewed patients. Secondary outcomes studied included risk factors associated with CAP caused by drug-resistant organisms, utilization of broad-spectrum antibiotics, appropriate antibiotic de-escalation within 72 hours, and treatment duration. In this 220-patient cohort, MRSA or PsA was isolated from three sputum cultures and no blood cultures. The local incidence of drug-resistant pathogens among the analyzed sample of CAP patients was 1.4% (n = 3/220). The overall incidence of CAP caused by MRSA or PsA among admitted patients is low at our safety-net county hospital. Future research is needed to identify local risk factors associated with the development of CAP caused by drug-resistant pathogens.IMPORTANCEThis study investigates the incidence of drug-resistant pathogens including methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa among community-acquired pneumonia (CAP) patients at a safety net hospital. Understanding local bacteria resistance patterns when treating CAP is essential and supported by evidence-based guidelines. Our findings empower other clinicians to investigate resistance patterns at their own institutions and identify methods to improve antibiotic use. This has the potential to reduce the unnecessary use of broad-spectrum antibiotic agents and combat the development of antibiotic resistance.

A Study on the Etiology and Clinical Manifestations of Community-Acquired Pneumonia in Adults in Western India.

Community-acquired pneumonia (CAP) is an acute lung infection affecting the alveoli in individuals who have not had recent exposure to healthcare settings. It is characterized by newly detected pulmonary infiltration on a chest X-ray or computed tomography scan, accompanied by at least two of the following symptoms: a new or worsening cough, shortness of breath, increased sputum production, fever or hypothermia, pleuritic chest pain, hypoxia, confusion, or an abnormal WBC count (either leukopenia or leukocytosis). It is a major contributor to global mortality and morbidity, especially in elderly populations. This study aims to investigate the etiology of CAP in our region and analyze the clinical characteristics of patients diagnosed with CAP. This prospective, hospital-based study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, a 2,011-bed multispecialty hospital. The study included 100 patients over 18 years old, diagnosed with CAP, and hospitalized between January 2023 and January 2024. All patients underwent a thorough clinical assessment, and sputum cultures were collected on the day of admission. Patients under 18 years old, those who had been hospitalized within the preceding two weeks, individuals with pneumonia caused by tuberculosis oraspiration pneumonia, patients with compromised immune systems, and pregnant women were excluded. The study included 100 patients with a mean age of 53.13 years (±18.31). The most common age group was 59-68 years, which included 25 (25%) cases, followed by the 69-78 yearage group with 18 (18%) cases and the 18-28 yearage group with 15 (15%) cases. The majority were male, with 61 (61%) cases. Common symptoms included fever in 78 cases (78%), chest pain in 69 cases (69%), dyspnea in 65 cases (65%), and cough in 51 cases (51%). Sputum cultures showed growth in 65 cases (65%), with Klebsiella pneumoniae being the most prevalent pathogen in 28cases (43%), followed by Streptococcus pneumoniae in 18 cases (28%). Together, these two pathogens accounted for 46 out of 65 positive samples (70%). This study highlights the clinical profile and rising etiology of K. pneumoniae in CAPin adults in Western India, particularly in the elderly. These findings underscore the need for periodic updates on CAP etiology to inform empirical treatment strategies effectively. Future research should use advanced diagnostics and diverse samples to refine CAP management, with continuous monitoring to update treatment protocols.

Controversies in the management of community-acquired pneumonia in adults.

Community-acquired pneumonia (CAP) is a common infectious syndrome in Australia and a leading global cause of morbidity and mortality. It drives a significant amount of antimicrobial prescribing in Australia. Accurate assessment and stratification of CAP severity is important. However, adequate evaluation is challenging and controversy remains about the optimal method. Streptococcus pneumoniae is the most commonly identified bacterial pathogen causing CAP. As such, oral amoxicillin monotherapy is the mainstay of empirical therapy for low-severity CAP. The need to start empirical therapy for pathogens such as Mycoplasma pneumoniae and Legionella species in low-severity CAP remains controversial; evaluating the causative pathogen on clinical grounds alone is difficult. Oral antibiotics recommended for CAP (e.g. amoxicillin, doxycycline) have excellent bioavailability and may be used instead of intravenous therapy in some hospitalised patients. A duration of 5 days of antibiotic therapy is recommended in clinical practice guidelines for patients with uncomplicated CAP who meet stability criteria at follow-up.

Role of biomarkers in community-acquired pneumonia management

Community-acquired pneumonia (CAP) poses a significant global health threat, particularly affecting vulnerable populations. Biomarkers and scoring systems play a crucial role in diagnosing, assessing severity, and guiding treatment decisions for CAP patients. Biomarkers like C reactive protein, procalcitonin, and the neutrophil-to-lymphocyte ratio aid in diagnosis and severity assessment, while scoring systems such as CURB-65 and Pneumonia Severity Index classify patients into risk categories. Emerging biomarkers (uremia, elevated respiratory rate, hypotension, and age ≥ 65) like serum amyloid A and S100 proteins show promise in predicting disease severity and prognosis. However, further research is needed to determine their precise roles and clinical utility in CAP management.

Efficacy and safety of vitamin C supplementation in the treatment of community-acquired pneumonia: a systematic review and meta-analysis with trial sequential analysis

Community-acquired pneumonia (CAP) poses a significant global health challenge, prompting exploration of innovative treatments. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of vitamin C supplementation in adults undergoing treatment for CAP. A comprehensive search of the MEDLINE, Embase, CINAHL, the Cochrane Central Register of Controlled Trials, and Clinical Trials.gov databases from inception to 17 November 2023 identified six randomized-controlled-trials (RCTs) meeting inclusion criteria. The primary outcome analysis revealed a non-significant trend towards reduced overall mortality in the vitamin C group compared to controls (RR 0.51; 95% CI 0.24 to 1.09; p = 0.052; I2 = 0; p = 0.65). Sensitivity analysis, excluding corona-virus-disease 2019 (COVID-19) studies and considering the route of vitamin C administration, confirmed this trend. Secondary outcomes, including hospital length-of-stay (LOS), intensive-care-unit (ICU) LOS, and mechanical ventilation, exhibited mixed results. Notably, heterogeneity and publication bias were observed in hospital LOS analysis, necessitating cautious interpretation. Adverse effects were minimal, with isolated incidents of nausea, vomiting, hypotension, and tachycardia reported. This meta-analysis suggests potential benefits of vitamin C supplementation in CAP treatment. However, inconclusive findings and methodological limitations warrants cautious interpretation, emphasising the urgency for high-quality trials to elucidate the true impact of vitamin C supplementation in CAP management.

Adverse outcomes in patients hospitalized with pneumonia at age 60 or more: A prospective multi-centric hospital-based study in India.

Limited data exists regarding risk factors for adverse outcomes in older adults hospitalized with Community-Acquired Pneumonia (CAP) in low- and middle-income countries such as India. This multisite study aimed to assess outcomes and associated risk factors among adults aged ≥60 years hospitalized with pneumonia. Between December 2018 and March 2020, we enrolled ≥60-year-old adults admitted within 48 hours for CAP treatment across 16 public and private facilities in four sites. Clinical data and nasal/oropharyngeal specimens were collected by trained nurses and tested for influenza, respiratory syncytial virus (RSV), and other respiratory viruses (ORV) using the qPCR. Participants were evaluated regularly until discharge, as well as on the 7th and 30th days post-discharge. Outcomes included ICU admission and in-hospital or 30-day post-discharge mortality. A hierarchical framework for multivariable logistic regression and Cox proportional hazard models identified risk factors (e.g., demographics, clinical features, etiologic agents) associated with critical care or death. Of 1,090 CAP patients, the median age was 69 years; 38.4% were female. Influenza viruses were detected in 12.3%, RSV in 2.2%, and ORV in 6.3% of participants. Critical care was required for 39.4%, with 9.9% in-hospital mortality and 5% 30-day post-discharge mortality. Only 41% of influenza CAP patients received antiviral treatment. Admission factors independently associated with ICU admission included respiratory rate >30/min, blood urea nitrogen>19mg/dl, altered sensorium, anemia, oxygen saturation <90%, prior cardiovascular diseases, chronic respiratory diseases, and private hospital admission. Diabetes, anemia, low oxygen saturation at admission, ICU admission, and mechanical ventilation were associated with 30-day mortality. High ICU admission and 30-day mortality rates were observed among older adults with pneumonia, with a significant proportion linked to influenza and RSV infections. Comprehensive guidelines for CAP prevention and management in older adults are needed, especially with the co-circulation of SARS-CoV-2.

Evaluating the utility of procalcitonin and a clinical decision support tool to determine duration of antimicrobial therapy for respiratory tract infections.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Procalcitonin (PCT) levels may play a role in decreasing the duration of antimicrobial therapy in institutions that have long durations of therapy for management of community-acquired pneumonia. We assessed the impact of the combination of pharmacist stewardship interventions assisted by a clinical decision support (CDS) tool and PCT assessment on the antimicrobial days of therapy (DOT) prescribed for respiratory tract infections (RTIs). We conducted a quasi-experimental study in which patients in the preintervention group were admitted between April and June 2021 and patients in the intervention group were admitted between April and June 2022. In the intervention phase, a CDS tool was utilized to alert clinical pharmacists when patients met specific criteria. This alert was programmed to activate for individual patients when a reported PCT level was less than 0.25ng/mL and on antimicrobials prescribed for an RTI as indicated by providers in the electronic health record. Stewardship interventions were made by pharmacists via prospective audit and feedback. The primary endpoint was inpatient antimicrobial DOT for RTIs. There were 90 patients in the preintervention group and 104 patients in the intervention group. Although baseline characteristics were not well matched between the groups, favoring the preintervention group, the median DOT was lower in the intervention group at 3 days (interquartile range [IQR], 2-4 days), compared to 4 days (IQR, 2.8-5 days) in the preintervention group (P = 0.001). The results of our study demonstrate the utility of pharmacist interventions coupled with CDS and PCT in reducing antimicrobial DOT prescribed for RTIs. Antimicrobial stewardship programs may benefit from implementing a PCT bundle.

Biomarkers: Are They Useful in Severe Community-Acquired Pneumonia?

Community acquired pneumonia (CAP) is a prevalent infectious disease often requiring hospitalization, although its diagnosis remains challenging as there is no gold standard test. In severe CAP, clinical and radiologic criteria have poor sensitivity and specificity, and microbiologic documentation is usually delayed and obtained in less than half of sCAP patients. Biomarkers could be an alternative for diagnosis, treatment monitoring and establish resolution. Beyond the existing evidence about biomarkers as an adjunct diagnostic tool, most evidence comes from studies including CAP patients in primary care or emergency departments, and not only sCAP patients. Ideally, biomarkers used in combination with signs, symptoms, and radiological findings can improve clinical judgment to confirm or rule out CAP diagnosis, and may be valuable adjunctive tools for risk stratification, differentiate viral pneumonia and monitoring the course of CAP. While no single biomarker has emerged as an ideal one, CRP and PCT have gathered the most evidence. Overall, biomarkers offer valuable information and can enhance clinical decision-making in the management of CAP, but further research and validation are needed to establish their optimal use and clinical utility.

Comparison Effects of Postural Drainage and Positive Expiratory Pressure Technique in Community Acquired Pneumonia

Background: Community-acquired pneumonia (CAP) is a major health concern worldwide, leading to substantial hospitalization and morbidity. Physiotherapy interventions like postural drainage and positive expiratory pressure (PEP) are commonly used in managing CAP, but their relative effectiveness in improving respiratory parameters is not fully understood. Objective: The study aimed to compare the effects of postural drainage and PEP techniques on respiratory parameters, specifically pH values and alveolar-arterial oxygen tension, in patients with CAP. Methods: In this randomized clinical trial, 46 patients with mild to moderate CAP were divided into two groups: postural drainage (n=23) and PEP technique (n=23). Data collection occurred pre- and post-intervention in each session, with analysis conducted using SPSS version 23. The Shapiro-Wilk test determined data normality, leading to the use of the Mann-Whitney U test for non-parametric data. Results: Improvements in oxygen saturation were observed in both groups. However, other arterial blood gas parameters, including pH and alveolar-arterial oxygen tension, showed no significant changes post-intervention. Specifically, pH values for the postural drainage group had mean ranks of 21.13, 22.04, 24.74, and 20.70 across sessions, while the PEP technique group showed mean ranks of 25.87, 24.96, 22.26, and 26.30, with p-values ranging from 0.152 to 0.525. Similarly, alveolar-arterial oxygen tension comparisons yielded p-values between 0.056 and 0.231. Conclusion: Both postural drainage and PEP techniques effectively improved oxygen saturation in CAP patients, but they did not significantly impact other respiratory parameters. This suggests their utility in specific areas of respiratory management in CAP, with limitations in broader pulmonary function improvement.

Community-Acquired Pneumonia in Children.

Community-acquired pneumonia (CAP) is the most common cause of childhood mortality globally. In the United States, CAP is a leading cause of pediatric hospitalization and antibiotic use and is associated with substantial morbidity. There has been a dramatic shift in microbiological etiologies for CAP in children over time as pneumococcal pneumonia has become less common and viral etiologies have become predominant. There is no commonly agreed on approach to the diagnosis of CAP in children. When indicated, antimicrobial treatment should consist of narrow-spectrum antibiotics. In this article, we will describe the current understanding of the microbiological etiologies, clinical presentation, diagnostic approach, risk factors, treatment, and future directions in the diagnosis and management of pediatric CAP.

39 Mind the CURB! Improving adherence to guidelines for management of community-acquired pneumonia

39 Mind the CURB! Improving adherence to guidelines for management of community-acquired pneumonia

Клинико-лабораторные предикторы тяжелой внебольничной пневмонии у детей до четырех лет

Community-acquired pneumonia (CAP) is a major cause of pediatric morbidity and mortality. Currently, there is no common approach to determination of CAP severity in children, which hampers early diagnosis and treatment of the disease. The study was aimed to determine clinical and laboratory predictors of severe CAP in children under 4 years of age. Analysis of clinical data, parameters of complete blood count (CBC), C-reactive protein (CRP) using nonparametric methods for hypothesis testing, univariate correlation analysis, cross-tabulation (Statistica 10.0), logistic regression, and ROC analysis (SPSS Statistics 20.0) was performed in 72 children aged 1 month to 3 years 11 months admitted to hospital due to CAP. Severe CAP was diagnosed in 16.7% of children. Causes of severe CAP included respiratory distress (moderate — 58.3%, severe — 16.7% of cases) and sepsis (25%). We identified significant clinical predictors of severe CAP: vomiting (OR 4.2), tachypnea (OR 28.3), chest wall retractions (OR 6), wheezing (OR 4), and the absence of rhinitis (OR 0.21). Isolated assessment of the CBC and CRP did not allow to predict CAP severity. We have developed a prediction model predicting severe CAP in children under 4 years of age based on the presence of rhinitis, tachypnea, as well as leukocyte count (sensitivity and specificity 91.7%). Thus, currently the main cause of severe CAP in children under 4 years of age is respiratory distress, in which wheezing predominates. Physical examination with an emphasis on detection of rhinitis and respiratory distress is essential for diagnosing severe CAP. The use of a pneumonia severity prediction model may contribute to improvement of management of CAP in patients under 4 years of age.

Diagnosis, treatment, and prevention of community-acquired pneumonia in children: an evidence-based clinical practice guideline adapted for the use in Egypt using ‘Adapted ADAPTE’

BackgroundWe recently adapted a guideline for Community-Acquired Pneumonia (CAP) in children to the Egyptian health system. Adaptation of evidence-based clinical practice guidelines to the local healthcare context is a valid alternative to de novo development that can upgrade their application without enforcing a major burden on resources. The objective of this manuscript is to elucidate diagnosis, treatment, and prevention of CAP as well as methods used for the adaptation process to produce the 1st National Guideline for Community-Acquired Pneumonia in children in Egypt using Adapted ADAPTE method. The full process was described extensively with all three phases of set up, adaptation, and finalization. An adaptation group and an external review including clinical content experts and methodologists conducted the process.ResultsThe authors adapted 10 principal categories of recommendations from three source Clinical Practice Guidelines. Recommendations incorporate; common clinical manifestations, indications for hospitalization and intensive care unit admission, indications for laboratory investigations and radiology in diagnosis, choice of empiric antibiotic therapy in the outpatient and hospitalized children with non-complicated CAP and the duration of therapy, the role of influenza antiviral therapy, follow-up anticipated response to therapy, management of non-responding pneumonia, criteria of safe discharge, and prevention of CAP. Many tools were gathered and established to improve implement ability containing two clinical algorithms for management of non-complicated CAP and for non-responding pneumonia in children, pathway for assessment of severity of CAP in primary care facilities, medication tables, simplified Arabic patient information, PowerPoint slide presentation lecture for management of CAP, and online resources.ConclusionThe final clinical guideline supports pediatricians and related healthcare workers with evidence-based applicable guidance for managing community-acquired pneumonia in Egypt. This work demonstrated the efficiency of Adapted ADAPTE and highlighted the importance of a cooperative clinical and methodological professional group for adaptation of national guidelines.