Professor, Department of Pediatrics and Emergency Medicine, Georgia Regents University, Augusta, GA 30912, USAUnited States
Assistant Residency Director, Department of Emergency Medicine, Georgia Regents Univer- sity, Augusta, GA 30912, USA In 2011 the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) and the British Thoracic Society (BTS) created extensive guide- lines with recommendations for the management of community acquired pneumonia in chil- dren.
Also available as PDF (figures and tables appear in the PDF).
There are a number of recommendations in these guidelines that seem to conflict with the evidence presented in the guidelines and elsewhere as well as clinical experience. The perceived disagreement between guidelines and clinical practice may be ours alone, but here are our thoughts and observations
• While the guidelines emphasize viral infections in the youngest patients and withholding antibiotics, the evidence shows that bacterial infections are also very common and that the morbidity and mortality of pneumonia are greatest for children under two years of age.
• Strong evidence exists that confirm combined bacterial and viral infections are common. And, the greatest benefit from the pneumococcal vaccine occurred with children under two years of age. These observations would strongly suggest that withholding antibiotics should only be performed when the clinician can be confident that the condition is most consistent with a solitary viral infection. Unfortunately, it is unclear at this time how to establish this diagnosis. • Existence of a viral infection does not rule out co-existent bacterial infection. Cessation of antibiotics should not be based solely on a positive viral panel, especially if the child appears ill.
• It is very challenging to accurately make the diagnosis without a chest radiograph. While it may be very appropriate to not obtain a chest radiograph in resource poor settings, we fear that the diagnosis of pneumonia with only the presence of cough and tachypnea will lead to an increasing overuse of antibiotics. Due to chest radiographs not being perfectly sensitive for pneumonia, clinicians may still consider the diagnosis of pneumonia based on physical examination findings alone. This seems very reasonable in ill appearing children, but should be done rarely in well appearing children to avoid the overuse of antibiotics.
• The prevalence of atypical causes of pneumonia is higher than once thought in young children. A Cochrane review revealed uncertainty about whether antibiotics should be routinely used in children with mycoplasma pneumonia. It seems reasonable to consider the use of antibiotics in patients with suspected or confirmed M. pneumoniae or C. pneumoniae pneumonia but more evidence is definitely needed.
The authors declare that they have no conflicts of interest.