This document summarizes challenges and opportunities in diagnosing and managing pneumonia in high-resource settings. It discusses how pneumonia is a common and costly condition in the US, with obstacles to identifying the pathogen. It also reviews chest imaging recommendations and severity scoring systems. Guidelines for outpatient and inpatient antibiotic treatment of pneumonia are presented. The document concludes by discussing quality improvement efforts to increase appropriate first-line antibiotic prescribing both in hospitals and communities.

1. Challenges and Opportunities in Diagnosing and
Managing Pneumonia in High Resource Settings
Todd Florin, MD, MSCE
Associate Professor
Director of Research, Division of Emergency Medicine
Lurie’s Children’s Hospital
Lilliam Ambroggio, PhD, MPH
Associate Professor
Sections of Emergency Medicine and Hospital Medicine
Children’s Hospital Colorado

2. Agenda

3. Pneumonia in the United States
0
200
400
600
800
1000
1200
1400
Newborn
Resp Dist
Synd
Pneumonia Chemotherapy Acute
Respiratory
Failure
Scoliosis
Standardized Cost in Millions, $
0
50000
100000
150000
200000
250000
Otitis Media Tonsillar
Hypertrophy
Asthma Bronchiolitis Pneumonia
Encounters, #
Source: Pediatric Health Information System, CHA
Keren R et al. Arch Pediatr Adol Med 2012
Each year: 2.6 million new cases of CAP, 1.5 million hospitalization, 3000 deaths due to CAP

4. Florin TA et al. Pediatrics 2013

5. Clin Infect Dis 2011:53 (1 October)

6. IDSA/PIDS Chest Radiography Recommendations

7. Clinical Features of CAP

8. Chest Radiography
Test M et al. J Hosp Med 2013

9. What about Ultrasound?
Pereda MA. Pediatrics 2015

10. Chest Radiography vs. Ultrasound
Ambroggio L et al. J Pediatr 2018

11. Risk Stratification

12. Ambiguous Risk Stratification in Children

13. CAP Severity Scores
Dean P and Florin TA. JPIDS 2018.
Dean P, Florin TA. JPIDS 2018

14. Prina E et al. The Lancet. 2015

15. PIDS/IDSA
Severity
Criteria
Bradley JS et al. Clin Infect Dis 2011

16. Validation of PIDS/IDSA Severity Criteria
Florin TA, Ambroggio L, Ruddy R, Shah S et al. Clin Infect Dis 2018

17. Severity Prediction in Hospitalized Children
Williams DJ et al. Pediatrics 2016
C-statistic
0.78-0.81

18. Biomarkers & Antibiotic Decisions
Schuetz P et al. JAMA 2009

19. Treatment of CAP

20. Obstacles to Diagnosing CAP
• Pathogen identified clinically in <20% of cases of childhood CAP
• Young children can’t provide sputum
• Blood cultures are uncommonly positive (<2%)
• Urinary antigen tests have poor specificity in children
• Many diagnostic tests not routinely performed
•Blood cultures are recommended in children with
moderate to severe CAP
•Viral PCR is recommended only in limited cases when
management decisions may change based on the results
(e.g. flu)
Shah SS. Arch Pediatr Adolesc Med 2003; Shah SS. Pediatr Infect Dis J
2011; Brogan TV. Pediatr Infect Dis J 2012
Obstacles to Identifying a Pathogen for CAP

21. Suspected pathogens in hospitalized children with pneumonia
• In the EPIC (Etiology of
Pneumonia in the
Community) study, 88
additional pathogens to
those shown in bar chart
were also detected
• Even using every molecular
and microbiological test
available, only 81% of
children with radiographic
pneumonia had a pathogen
identified
Jain et al. NEJM 2015

22. Antibiotics are given empirically which can lead to
overuse and increase the prevalence of drug-
resistant organisms in the community

23. Prior to 2011 no U.S. guideline existed for appropriate antibiotic
therapy for CAP
Ambroggio L. Pediatr Infect Dis J 2012;31:331-336

24. Treatment Through the Continuum Of
Management for CAP
Community
Practices
Emergency
Department
Hospitalization
Home

25. Antibiotic Choice-Outpatient
Age of Child Infant /Preschool Aged School Aged
Recommendation No antibiotics Amoxicillin Amoxicillin Azithromycin
Comments Antibiotics
NOT routinely
required,
because viral
pathogens are
most
prevalent.
First-line therapy
if previously
healthy &
immunized.
Provides
excellent
coverage for
S. pneumoniae
First-line
therapy if
previously
healthy &
immunized.
For treatment of
older children
with findings
compatible with
CAP caused by
atypical
pathogens.
Strength Strong Strong Strong Weak
Evidence Quality High Moderate Moderate Moderate

26. First Line Second Line
Recommendation Ampicillin / PCN G 3rd Generation Cephalosporin
Comments
Immunized infant,
preschool, or school-age
child.
Non-immunized, in regions with
high levels of PCN resistant
pneumococcal strains, or in life-
threatening infection/empyema.
Strength Strong Weak
Evidence Quality Moderate Moderate
Antibiotic Choice—Inpatient

27. Atypical Bacteria S. aureus
Recommendation Macrolide Vancomycin or Clindamycin
Comments
In addition to beta-lactam
therapy if atypical bacteria are
significant considerations.
Instead of beta-lactam if
findings are characteristic of
atypical infection.
In addition to beta-lactam
therapy if clinical, laboratory,
or imaging characteristics are
consistent with infection
caused by S. aureus.
Recommendation
Strength
Weak Strong
Evidence Quality Moderate Low
Antibiotic Choice—Inpatient Secondary Agents

28. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
5/1/2011(n=03)
5/15/2011(n=03)
5/22/2011(n=02)
5/29/2011(n=06)
6/5/2011(n=05)
6/19/2011(n=03)
6/26/2011(n=01)
7/10/2011(n=01)
7/17/2011(n=01)
7/24/2011(n=03)
7/31/2011(n=01)
8/8/2011(n=01)
8/15/2011(n=02)
8/22/2011(n=02)
8/29/2011(n=04)
9/5/2011(n=02)
9/12/2011(n=03)
9/19/2011(n=05)
9/26/2011(n=03)
10/3/2011(n=02)
10/10/2011(n=03)
10/17/2011(n=03)
10/24/2011(n=02)
10/31/2011(n=01)
11/7/2011(n=02)
11/14/2011(n=05)
11/21/2011(n=02)
11/28/2011(n=04)
12/5/2011(n=04)
12/12/2011(n=06)
12/26/2011(n=04)
1/2/2012(n=05)
1/9/2012(n=03)
1/16/2012(n=07)
1/23/2012(n=05)
1/30/2012(n=03)
2/20/2012(n=05)
3/5/2012(n=09)
3/12/2012(n=03)
3/19/2012(n=07)
3/26/2012(n=05)
4/2/2012(n=06)
4/9/2012(n=04)
4/16/2012(n=04)
4/23/2012(n=04)
4/30/2012(n=04)
5/7/2012(n=03)
5/14/2012(n=05)
5/21/2012(n=02)
5/28/2012(n=01)
6/4/2012(n=02)
6/11/2012(n=02)
6/18/2012(n=01)
6/25/2012(n=01)
7/2/2012(n=02)
7/7/2012(n=01)
7/14/2012(n=01)
7/21/2012(n=01)
PercentageofAppropriate1stLineAntibiotics
Week of service (n=Number of patients with Pneumonia)
1st Line Antibiotic Prescribing in the Emergency Department
May 2011-July 2012
Weekly Averages Median Goal
Quality Improvement Science to Increase Guideline Recommended Antibiotics in
the Hospital

29. Quality Improvement Science to Increase Guideline Recommended Antibiotics in the
Community

30. Questions?