PNEUMONIA, COMMUNITY-ACQUIRED

JEFFREY SEIDEN, MD AND JAMES M. CALLAHAN, MD

BACKGROUND (EPIDEMIOLOGY, EVIDENCE)

Globally, pneumonia is the leading cause of mortality in children under 5 years of age, accounting for nearly 20% of all such deaths. In the United States, community-acquired pneumonia (CAP) is the most common serious bacterial infection in childhood, accounting for approximately 3 million outpatient visits per year. Further, CAP is one of the most common reasons for inpatient hospitalizations; for every 100,000 children under 19 years of age, 200 will be hospitalized with CAP. Despite the frequency with which physicians encounter CAP in the emergency department (ED), there exists a tremendous degree of practice variation with respect to the diagnosis, management, and disposition for children with suspected CAP. Even when adjusting for level of severity, rates of inpatient admission for pneumonia vary from 19% to 69% among freestanding US children’s hospitals. Similar variability exists in the rates of ED resource utilization, such as diagnostic imaging and laboratory evaluation, as well as in the use of antimicrobial agents. As a result, efforts to standardize care and optimize outcomes are essential. Development and implementation of clinical pathways are an effective method for increasing the value of healthcare.

There are two main areas that warrant special attention in the development of a clinical pathway for CAP: diagnostic testing and antibiotic treatment. A wide variability has been described in the use of radiographic imaging, blood tests, and viral studies among inpatients with CAP in freestanding children’s hospitals in the United States. Increased diagnostic testing was associated with increased hospital length of stay, but had no effect on other outcomes, such as hospital readmission after discharge. In addition, increased testing has been associated with a higher frequency of broad-spectrum antibiotic usage. Despite solid evidence that broad-spectrum antibiotics, including cephalosporins and macrolides, provide little benefit over penicillins in the treatment of CAP, they continue to be prescribed quite frequently. The majority of children admitted to the hospital for the treatment of CAP are actually treated in community hospitals and children’s hospitals within larger hospitals. In one retrospective cohort study, a similar variability in diagnostic testing has been shown to exist in these settings. There was decreased variability in the choice of antibiotic regimen in these settings but unfortunately more than 75% of patients in this review of an administrative database were inappropriately treated with a third-generation cephalosporin as part of their regimen and 10% were treated with macrolides alone, which frequently do not provide adequate coverage for the organisms which most often cause CAP in children. Creating evidence-based, consensus guidelines to standardize the approach to CAP aims to minimize unnecessary diagnostic testing, prevent the unnecessary use of broad-spectrum antibiotics, and ensure the best possible outcomes for children presenting with suspected CAP. The Pediatric Infectious Diseases Society (PIDS) and Infectious Disease Society of America (IDSA) have issued clinical guidelines that may be used to guide the development of local guidelines in 2011. Quality improvement efforts, in particular rapid tests of change using plan-do-study-act cycles, have been shown to be an effective way to produce a rapid increase in compliance with such guidelines. A web-based pathway allows ready access to evidence and expert consensus to the clinicians at the point of care to provide support to clinical decision making for all team members.