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Philippine PCAP guidelines

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  • ______________________________________________________________

    AnOfficialPublicationofthePhilippineAcademyofPediatricPulmonologists,Inc.

    ______________________________________________________________

    PAPPPERSPECTIVE

    Updates

    inthe

    EvaluationandManagementof

    PediatricCommunity-AcquiredPneumonia

    PAPPTaskForceonpCAP[2008]

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    PhilippineAcademyofPediatricPulmonologists,Inc.[PAPP,Inc.]2008

    Allrightsreserved.PublicationandrequestforpermissiontoreproducecanbeobtainedfromthePhilippineAcademyofPediatricPulmonologists,Inc.,Room102GJBuilding,385QuezonAvenueQuezonCityTelefaxNo+6323747201;email:papp_office@yahoo.com.

    Thisdocumentisnotintendedtobeastandardofcare.Theresponsibilityforitsuselieswiththereader.InnoeventshallPAPP,Inc.beliablefordamagesarisingfromitsuse.

    PAPPOfficers OliviaC.Go,MDFPPSFPAPP.President ArnelGeraldQ.Jiao,MDFPPSFPAPP....Vice-President CesarM.Ong,MDFPPSFPAPP...Secretary MariaNerissaA.deLeon,MDFPPSFPAPP....Treasurer MaryThereseM.Leopando,MDFPPSFPAPP.Director ClaraR.Rivera,MDFPPSFPAPP.Director MaryAnnF.Aison,MDFPPSFPAPP...Director

    PAPPTaskForceonpCAPCristanQ.Cabanilla,MDFPPSFPAPP

    ChairReginaM.Canonizado,MDFPPSFPAPPAnjanetteR.deLeon,MDDPPSDPAPPRoslynMarieK.Dychiao,MDFPPSDPAPPBeatrizPraxedesApollaI.Mandanas-Paz,MDDPPSDPAPPAnnaMarieS.Putulin,MDFPPSFPAPPEmilyDoloresG.Resurreccion,MDFPPSFPAPPAnaMariaA.Reyes,MDFPPSFPAPPMarionO.Sanchez,MDDPPSDPAPPRitaMarieLourdesS.Vergara,MDFPPSFPAPPRozaidaR.Villon,MDFPPSFPAPP

    MembersGerardoL.Beltran,MDFPCR

    GuestRadiologistGladysL.Gillera,MDDPPSDPAPP

    Secretary

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    CONTENTS

    Foreword

    PrefacetotheUpdatesandAcknowledgement

    2004ClinicalPracticeGuidelineClinicalQuestionswithRecommendations,andUpdateHighlightswithAnnotations

    Appendix

    Bibliography

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    FOREWORD

    Inthepastyears,wewitnessedamajorrevolutioninthescienceandpracticeofpediatricpulmonarymedicine,moreparticularlyinourconceptandmanagementofpneumoniainchildren.Wearechallengedtoadoptandapplythesenewerinsightsaboutthediseaseindealingwithourpatients.

    Despite the inadequate and limited advancement in medical technology amongdeveloping countries, we are able to establish the diagnosis of pneumonia and manage itcomprehensivelylargelybasedongoodclinicalacumen.Furthermore,ourknowledgeinclinicalepidemiology is imperative to facilitate its holistic management, while the rational use ofantimicrobial agents increases our awareness on the emergence of drug resistance in specificlocalities.

    Thisclinicalupdateonpneumoniacontainsacomprehensiveevidence-based reviewofnational as well as international researches that depicts the current clinical practice andmanagement strategies adopted to contain the disease. The Academy maintains its primarypurpose toappriseourpediatricpractitionersof themanymedicalinvestigationsonpneumoniaandproposepracticaltreatmentoptionstocombatthedisease.

    Thiscurrentissuedoesnotintendtoreplacethe2004PPSClinicalPracticeGuidelineinthe Management of Pediatric Community-Acquired Pneumonia. This is simply presented toclarify some gaps in the knowledge stated therein. We look forward that this understandingbridgesthesmalldifferencesinourdailypracticetobringforthaworthyclinicaloutcome.

    AllowmetotakethisgoodopportunitytocongratulatetheTaskForceonPCAPforsuchanexcellentjob.

    OliviaC.Go,MDPresidentPhilippineAcademyofPediatricPulmonologists,Inc.

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    PREFACETOTHEUPDATES

    Oneof the issues thatwas raised regarding the2004ClinicalPracticeGuideline in theEvaluation and Management of Pediatric Community-Acquired Pneumonia is the gap inknowledge underscored in each recommendation. To address this concern, the Task Force onpCAPhasrevieweddataavailablefromlocalandforeignliterature.Asthismanuscriptismerelyanupdateconsistingofrecentliterature,itisnotintendedtobeastandardofcaremuchmorearevisionofthecurrentguideline.

    This update is available in two formats. The abbreviated format consists of updatehighlightsandsummaryofrecentevidence.Thisismadeavailableasalimitedserviceitemintheformofhardcopyduringthe200816thPAPPAnnualConvention.Thecompleteversionwhichincludesnotonlysimilarhighlightsbutdetaileddescriptionofeachupdatecanbedownloadedfrom the Philippine Academy of Pediatric Pulmonologists, Inc. through the website of thePhilippine Pediatric Society www.pps.org.ph. The reader is encouraged to access the completeversionforamorethoroughdiscussion.

    CristanQCabanilla,MDChairTaskForceonpCAP

    Acknowledgement

    ThismanuscriptistheresultofaconcertedeffortbytheTaskForceonpCAPundertheleadershipandguidanceofthePAPPofficersheadedbyOliviaC.Go.SpecialgratitudeisduetoLuisM.RiveraSr.,AlexanderO.Tuazon,MilagrosS.BautistaandAgnesR.Mendozaforreviewingthedocument.

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    2004CLINICALPRACTICEGUIDELINECLINICALQUESTIONSWITHRECOMMENDATIONS,AND

    UPDATEHIGHLIGHTSWITHANNOTATIONS

    ClinicalQuestions[CQ]

    Evaluation

    1.Whoshallbeconsideredashavingcommunity-acquiredpneumonia?2.Whowillrequireadmission?3. Whatdiagnosticaidsareinitiallyrequestedforambulatorypatients?4. Whatdiagnosticaidsareinitiallyrequestedforin-patients?

    Treatment

    5.Whenisantibioticrecommended?6.Whatempirictreatmentshouldbeadministeredifabacterialetiology

    isstronglyconsidered?7. Whattreatmentshouldbeinitiallygivenifaviraletiology

    isstronglyconsidered?8.Whencanapatientbeconsideredasrespondingtothecurrent

    antibiotic?9.Whatshouldbedoneifapatientisnotrespondingtocurrent

    antibiotictherapy?10.Whencanswitchtherapyinbacterialpneumoniabestarted?11.Whatancillarytreatmentcanbegiven?

    Prevention

    12.Howcanpneumoniabeprevented?

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    INTRODUCTION

    Theworldincidenceoflowerrespiratorytractinfectionthatincludespneumoniain developing countries has been recently estimated to be 150.7 million cases, 95% ofwhomareunderfiveyearsofage,and13%severeenoughtorequirehospitaladmission[Rudan I,2004]. In the Philippines, it continues to be a leading cause of morbidity inchildrenaccountingtoabout828.8per100,000population[DepartmentofHealthFieldHealthServiceInformationSystem,2006].

    Estimates of treatment cost highlight the economic burden that childhoodpneumonia places on health care systems. An average cost of treatment for acuterespiratory infectionperepisodefromtheperspectiveofdevelopingeconomies inAsiarangedfromUSD1.70 inaprimaryhealthcare setting toUSD155.30forhospitalizedcare [Toan NV,2001; Rattanadilok N,2002]. Outpatient and hospitalized care of a child withpneumoniahavebeenestimatedtobeUSD13.44andUSD71.0perepisode,respectively[HussainH,2006]. Anaverageparents totalhouseholdexpenses forachildsadmissionbecause of pneumonia have been found to be 5 to 11% of an average net income perfamily in Israel [Shoham Y,2005]. In the local setting asprovidedby theNationalHealthInsuranceProgram,the2006totalpaymentclaimsforpneumonia[ICD-10CodeJ18.9]below19yearsofageamountedtoPhP324.688M[PhilippineHealthInsuranceCorporation,ClaimsPaymentSummaryforCY2006Ages0-19forPneumonia,2007].

    One public health strategy to address this continuing concern is theimplementationofaclinicalpracticeguideline.In2004,thePhilippinePediatricSociety,thePhilippineAcademyofPediatricPulmonologistsandthePediatricInfectiousDiseaseSocietyof thePhilippines cameoutwith a clinical practice guideline in the evaluationand management of pediatric community-acquired pneumonia. In 2006, the PhilippineHealthInsuranceCorporationhasadoptedthedocumentasoneoftheguidelinesthatcanserve as a basis for quality assurance and accreditation [PhilHealth Health TechnologyAssessmentUnit,QualityAssuranceResearchandPolicyDevelopmentGroup,2006].Itsacceptabilityand utilization have been subsequently assessed. Of the 166 respondents to a randomsamplingquestionnairesurveyconductedduringthe200643rdPPSAnnualConvention,82%acknowledgedapplying the recommendation in their practice [Cabanilla C, Santos J,2006].Inanothersurveyamong61pediatricconsultantsandresidentsfromMetroManila,about96%confirmedthatsuchguidelinewasbeingfollowed[deJesus-OabelBAandAtienza-deLeonMN,2007].

    Thisupdatepresentsevidencesbasedonrecentlocalandforeignliteraturedealingwiththerecognitionofcommunity-acquiredpneumoniainanimmunocompetentpatientaged 2 months to 19 years, identification of appropriate and practical diagnosticprocedures,andinitiationofrationalmanagementandpreventivemeasures

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    CQ1.Whoshallbeconsideredashavingcommunity-acquiredpneumonia?

    2004ClinicalPracticeGuidelineRecommendation

    Predictorsofcommunity-acquiredpneumoniainapatientwithcough

    1.forages3monthsto5yearsaretachypneaand/orchestindrawing[GradeB].

    2.forages5to12yearsarefever,tachypnea,andcrackles[GradeD].

    3.beyond12yearsofagearethepresenceofthefollowingfeatures[GradeD]:

    a.fever,tachypnea,andtachycardia;and

    b.atleastoneabnormalchestfindingsofdiminishedbreathsounds,rhonchi,cracklesorwheezes.

    UPDATEHIGHLIGHTS

    1. Apatientpresentingwithahistoryofcoughand/orrespiratorydifficultyshouldbeevaluatedforthepossiblepresenceofpneumonia.However,thelackofcough does not necessarily imply the absence of the disease as it may not bepresent as an initial presentation in24%of caseswith radiographicpneumonia.Thisisparticularlytrueintheyoungeragegroup.

    2. Therearephysicalsignsthatareusefultopredictthepresenceofpneumoniausingchestxrayasreferencestandard.Infourstudiesinvolvingchildrenbelow5yearsold,age-specifictachypneaasdefinedbytheWorldHealthOrganization[WHO]remainstobethebestsinglepredictor.Anotherusefulsinglephysicalsignisthepresenceofchestindrawing.Acombinationoftachypneaandchestindrawingprovidesahigherprobabilityasto thepresenceofpneumonia. Inone study, the combinationof tachypnea, lowoxygen saturation on admission and nasal flaring gave the highest predictivevalueamongallothersignsandsymptoms.Intwostudiesdealingwit