Management of community-acquired pneumonia in children : South African Thoracic Society guidelines (Part 3)

Abstract

BACKGROUND. Pneumococcal conjugate vaccine (PCV) administration and other advances have been associated with a shift in the aetiological spectrum of community-acquired pneumonia, necessitating reconsideration of empiric antibiotic treatment guidelines. Management strategies have also evolved in the last decade. OBJECTIVES. To produce revised guidelines for the treatment of pneumonia in South African (SA) children, including ambulatory, hospital and intensive care management. METHODS. An expert subgroup, reviewing evidence on the management of childhood pneumonia, was convened as part of a broader group revising SA guidelines. Evidence was graded using the British Thoracic Society (BTS) grading system and recommendations were made. RESULTS. Antibiotic treatment depends on the child’s age, possible aetiology, antimicrobial resistance patterns, previous treatment, as well as factors affecting host susceptibility, including HIV, and nutritional and vaccination status. All children with signs of severe pneumonia should receive antibiotics. Children <1 month of age with pneumonia should be hospitalised and treated with ampicillin and an aminoglycoside. For treatment of ambulatory children >1 month of age, high-dose amoxicillin remains the preferred antibiotic. For severe pneumonia in this age group, hospitalisation and empiric treatment with amoxicillin-clavulanate orally is recommended; if oral therapy is not tolerated, intravenous therapy is recommended. Generally, 5 days of therapy is proposed, but longer duration may be needed in cases of severe or complicated disease. A macrolide antibiotic should be used if pertussis, mycoplasma or chlamydia pneumonia is suspected. Most hypoxic children can receive oxygen via nasal cannulae, but respiratory support should be individualised and extends to non-invasive and invasive ventilation in some cases. Children should be fed enterally; if this is not possible, administer intravenous isotonic fluids at <80% of maintenance, with monitoring of sodium levels. Empiric antibiotic treatment is the same in HIV-infected, HIV-exposed uninfected and HIV-uninfected children, although treatment for pneumocystis pneumonia and/or cytomegalovirus pneumonia should be considered in HIV-infected infants, especially in the absence of combination antiretroviral therapy. CONCLUSIONS. Updated guidelines optimise the management of childhood pneumonia in the context of changing epidemiology, improvements in HIV prevention and new evidence on management.