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thorax.bmj.com Guidelines for the management of community acquired pneumonia in children: update 2011 British Thoracic Society Community Acquired Pneumonia in Children Guideline Group October 2011 Volume 66 Supplement 2 Thorax AN INTERNATIONAL JOURNAL OF RESPIRATORY MEDICINE Michael Harris, Julia Clark, Nicky Coote, Penny Fletcher, Anthony Harnden, Michael McKean, Anne Thomson Community Acquired Pneumonia in Children Guideline Group On behalf of the British Thoracic Society Standards of Care Committee Journal of the British Thoracic Society Impact Factor: 6.53 Editors A Bush (UK) I Pavord (UK) Deputy Editors P Cullinan (UK) C Lloyd (UK) Associate Editors R Beasley (New Zealand) A Jones (UK) J Brown (UK) E Lim (UK) JC Celedo´n (USA) N Maskell (UK) A Custovic (UK) JL Pepin (France) A Fisher (UK) T Sethi (UK) P Gibson (Australia) M Steiner (UK) J Grigg (UK) D Thickett (UK) D Halpin (UK) H Zar (South Africa) Statistical Editors J Gibson (UK) Statistical Advisor T McKeever (UK) Lung Alert Editor J Quint (UK) President, British Thoracic Society E Neville Editorial Office BMJ Publishing Group Ltd, BMA House, Tavistock Square, London WC1H 9JR, UK T: +44 (0)20 7383 6373 F: +44 (0)20 7383 6668 E: thorax@bmjgroup.com ISSN: 0040-6376 (print) ISSN: 1468-3296 (online) Disclaimer: Thorax is owned and published by the British Thoracic Society and BMJ Publishing Group Ltd, a wholly owned subsidiary of the British Medical Association. 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Copyright: � 2011 BMJ Publishing Group Ltd and the British Thoracic Society. All rights reserved; no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of Thorax. Thorax is published by BMJ Publishing Group Ltd, typeset by TNQ Books & Journals, Chennai, India and printed in the UK on acid-free paper by Buxton Press, Buxton, UK. Thorax (ISSN No: 0040–6376) is published monthly by BMJ Publishing Group and distributed in the USA by Mercury International Ltd. Periodicals postage paid at Rahway, NJ. POSTMASTER: send address changes to Thorax, Mercury International Ltd, 365 Blair Road, Avenel, NJ, 07001, USA. BTS guidelines ii1 Abstract ii1 Synopsis of recommendations ii2 1. Introduction and methods ii3 2. Incidence and economic consequences ii5 3. Aetiology ii8 4. Clinical features ii9 5. Radiological, general and microbiological investigations ii13 6. Severity assessment ii14 7. General management in the community and in hospital ii15 8. Antibiotic management ii18 9. Complications and failure to improve ii19 10. Prevention and vaccination ii20 11. Audit criteria ii20 References Online Appendix 1 Search strategy Online Appendix 2 Template data collection form Contents Volume 66 Supplement 2 | THORAX October 2011 British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011 Michael Harris,1 Julia Clark,2 Nicky Coote,3 Penny Fletcher,4 Anthony Harnden,5 Michael McKean,6 Anne Thomson,1 On behalf of the British Thoracic Society Standards of Care Committee ABSTRACT The British Thoracic Society first published management guidelines for community acquired pneumonia in children in 2002 and covered available evidence to early 2000. These updated guidelines represent a review of new evidence since then and consensus clinical opinion where evidence was not found. This document incorporates material from the 2002 guidelines and supersedes the previous guideline document. SYNOPSIS OF RECOMMENDATIONS Clinical features < Bacterial pneumonia should be considered in children when there is persistent or repetitive fever >38.58C together with chest recession and a raised respiratory rate. [D] Investigations < Chest radiography should not be considered a routine investigation in children thought to have community acquired pneumonia (CAP). [A�] < Children with signs and symptoms of pneu- monia who are not admitted to hospital should not have a chest x-ray. [A�] < A lateral x-ray should not be performed routinely. [B�] < Acute phase reactants are not of clinical utility in distinguishing viral from bacterial infections and should not be tested routinely. [A�] < C reactive protein is not useful in the manage- ment of uncomplicated pneumonia and should not be measured routinely. [A+] < Microbiological diagnosis should be attempted in children with severe pneumonia sufficient to require paediatric intensive care admission, or those with complications of CAP. [C] < Microbiological investigations should not be considered routinely in those with milder disease or those treated in the community. [C] < Microbiological methods used should include: – Blood culture. [C] – Nasopharyngeal secretions and/or nasal swabs for viral detection by PCR and/or immunoflu- orescence. [C] – Acute and convalescent serology for respira- tory viruses, Mycoplasma and Chlamydia. [B+] – If present, pleural fluid should be sent for microscopy, culture, pneumococcal antigen detection and/or PCR. [C] – Urinary pneumococcal antigen detection should not be done in young children. [C] Severity assessment < For a child in the community, re-consultation to the general practitioner with persistent fever or parental concern about persistent fever should prompt consideration of CAP. [D] < Children with CAP in the community or in hospital should be reassessed if symptoms persist and/or they are not responding to treatment. [D] < Children who have oxygen saturations <92% should be referred to hospital for assessment and management. [B+] < Auscultation revealing absent breath sounds with a dull percussion note should raise the possibility of a pneumonia complicated by effusion and should trigger a referral to hospital. [B�] < A child in hospital should be reassessed medi- cally if there is persistence of fever 48 h after initiation of treatment, increased work of breathing or if the child is becoming distressed or agitated. [D] General management < Families of children who are well enough to be cared for at home should be given information on managing fever, preventing dehydration and identifying any deterioration. [D] < Patients whose oxygen saturation is#92% while breathing air should be treated with oxygen given by nasal cannulae, high flow delivery device, head box or face mask to maintain oxygen saturation >92%. [B] < Nasogastric tubes may compromise breathing and should therefore be avoided in severely ill children and especially in infants with small nasal passages. If use cannot be avoided, the smallest tube should be passed down the smallest nostril. [D] < Plasma sodium, potassium, urea and/or creati- nine should be measured at baseline and at least daily when on intravenous fluids. [C] < Chest physiotherapy is not beneficial and should not be performed in children with pneumonia. [A�] Antibiotic management < All children with a clear clinical diagnosis of pneumonia should receive antibiotics as bacterial < Additional appendices are published online only. To view these files please visit the journal online (http://thorax.bmj. com). 1Oxford Children’s Hospital, The John Radcliffe, Headington, Oxford, UK 2Department of Paediatric Immunology and Infectious Diseases, Old COPD, Great North Children’s Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK 3Children’s Ambulatory Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK 4Pharmacy Department, Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK 5Department of Primary Health Care, University of Oxford, Headington, Oxford, UK 6Department of Paediatric Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK Correspondence to Anne Thomson, Oxford Children’s Hospital, The John Radcliffe, Headley Way, Headington, Oxford OX3 9DU, UK; anne.thomson@orh.nhs.uk Received 10 June 2011 Accepted 16 June 2011 Thorax 2011;66:ii1eii23. doi:10.1136/thoraxjnl-2011-200598 ii1 BTS guidelines and viral pneumonia cannot reliably be distinguished from each other. [C] < Children aged <2 years presenting with mild symptoms of lower respiratory tract infection do not usually have pneumonia and need not be treated with antibiotics but should be reviewed if symptoms persist. A history of conjugate pneumococcal vaccination gives greater confidence to this decision. [C] < Amoxicillin is recommended as first choice for oral antibiotic therapy in all children because it is effective against the majority of pathogens which cause CAP in this group, is well tolerated and cheap. Alternatives are co-amoxiclav, cefaclor, erythromycin, azithromycin and clarithromycin. [B] < Macrolide antibiotics may be added at any age if there is no response to first-line empirical therapy. [D] < Macrolide antibiotics should be used if either mycoplasma or chlamydia pneumonia is suspected or in very severe disease. [D] < In pneumonia associated with influenza, co-amoxiclav is recommended. [D] < Antibiotics administered orally are safe and effective for children presenting with even severe CAP and are recom- mended. [A+] < Intravenous antibiotics should be used in the treatment of pneumonia in children when the child is unable to tolerate oral fluids or absorb oral antibiotics (eg, because of vomiting) or presents with signs of septicaemia or complicated pneumonia. [D] < Recommended intravenous antibiotics for severe pneumonia include amoxicillin, co-amoxiclav, cefuroxime and cefotaxime or ceftriaxone. These can be rationalised if a microbiological diagnosis is made. [D] < In a patient who is receiving intravenous antibiotic therapy for the treatment of CAP, oral treatment should be considered if there is clear evidence of improvement. [D] Complications < If a child remains feverish or unwell 48 h after treatment has commenced, re-evaluation should be performed with consid- eration given to possible complications. [D] < Children with severe pneumonia, empyema and lung abscesses should be followed up after discharge until they have recovered completely and their chest x-ray has returned to near normal. [D] Follow-up < Follow-up radiography is not required in those who were previously healthy and who are recovering well, but should be considered in those with a round pneumonia, collapse or persisting symptoms. [B+] 1. INTRODUCTION AND METHODS The British Thoracic Society (BTS) first published management guidelines for community acquired pneumonia (CAP) in children in 2002 and covered available evidence to early 2000. These updated guidelines represent a review of new evidence since then and consensus clinical opinion where evidence was not found. As before, these guidelines have been produced in parallel with those produced for adults, which have also been updated. This document incorporates material from the 2002 guidelines and supersedes the previous guideline document. CAP can be defined clinically as the presence of signs and symptoms of pneumonia in a previously healthy child due to an infection which has been acquired outside hospital. In developed countries this can be verified by the radiological finding of consolidation. In the developing world a more practical termdacute lower respiratory tract infectiondis preferred, reflecting the difficulties in obtaining an x-ray. Ideally, the definition would include the isolation of a responsible organism. However, it is apparent from many studies that a pathogen is not identified in a significant proportion of cases that otherwise meet the clinical definition (see Section 3). As it is assumed that CAP is caused by infection, the presumption is that current techniques have insufficient sensitivity to detect all relevant pathogens. Treatment guidelines therefore have to assume that, where pathogens are isolated, they represent all likely pathogens. There is a clear need for better diagnostic methods. In creating guidelines it is necessary to assess all available evidence with consideration of the quality of that evidence. This we have endeavoured to do. We have then produced a combina- tion of evidence statements and recommendations about management based on the available evidence, supplemented by consensus clinical opinion where no relevant evidence was found. The guideline is framed in each chapter as a list of key ques- tions that are then explored and discussed. These questions were set based upon previous guidelines and those raised in the adult CAP guideline. Methods of guideline development Scope of guidelines These guidelines address the management of CAP in infants and children in the UK. They do not include neonates, infants with respiratory syncytial virus bronchiolitis or children with upper respiratory tract infection, mild fever and wheeze. The specific management of children with pre-existing respiratory disease or that of opportunistic pneumonias in immunosuppressed chil- dren is not addressed. Guideline development group The guideline development group was set up by the BTS Stan- dards of Care Committee and comprised two paediatricians with a special interest in respiratory disease, a paediatrician with a special interest in paediatric infectious diseases, a general paediatrician with a special interest in ambulatory paediatrics, a specialist trainee in paediatrics, a general practitioner with an interest in childhood infection and a paediatric pharmacist. An information specialist developed the search strategy and ran the searches. No external funding was obtained to support the development of the guidelines. Identification of evidence A search strategy was developed by an information specialist from the Centre for Reviews and Dissemination in York (part of the National Institute for Health Research). The Search strategy and the results are shown in appendix 1 in the online supplement. The Cochrane Library (DARE and Cochrane Database of Systematic Reviews), MEDLINE and EMBASE were searched from 2000 onwards. There were some technical changes made to the original search strategies to reduce the chances of missing studies: a single search strategy was used rather than separate strategies for each subject. Studies were limited to English language in view of the limitations on time and resources. ii2 Thorax 2011;66:ii1eii23. doi:10.1136/thoraxjnl-2011-200598 BTS guidelines Two thousand and seventy-six studies were identified by the searches, which were rerun in July 2010. The updated search identified a further 511 titles. Assessing the literature Initial review of the 2076 titles and abstracts was undertaken by one reviewer, screening for relevance. This was repeated after the second search by another reviewer. The relevant titles and abstracts were grouped by subject matter with many papers being relevant for more than one subject area. Two reviewers then assessed the studies for inclusion. Studies from countries where the populations or clinical practices were very different from the UK were excluded unless they addressed questions that could be generalised to the UK (such as clinical assessment). Any differences of opinion were settled by a third party. The studies were appraised using the Cochrane data extraction template (see appendix 2 in online supplement). Any guideline statements made were graded using the same table as that used by the group developing the adult guidelines (table 1).1 First, each paper was given an evidence level (Ia to IVb) by the authors of each chapter. Then, at the end of each chapter when evidence statements were collated, a summative evidence level was attached to each statement depending on the level of evidence underpinning that statement. Finally, each recommendation was graded (A to D) based upon a considered judgement of the body of evidence. Review of the guideline The guideline is due for review in 3 years from the date of publication. Provenance and peer review The draft guideline was made available online for public consultation (January/February 2011). The draft guideline was reviewed by the BTS Standards of Care Committee (July 2010/ March 2011). 2. INCIDENCE AND ECONOMIC CONSEQUENCES 2.1 How common is CAP in children in the community and in hospital? Two recent European papers give incidence rates for CAP in children seen in hospital (table 2) which are lower than those reported previously from the 1980s in Finland.2[Ib] A prospective population-based study of 278 Norwegian children aged <16 years seen in hospital with pneumonia (temperature, clinical signs and chest x-ray infiltrate in previ- ously well child) from 2003 to 2005 in Oslo gave population incidence rates per 10 000 of 14.7 in children aged 0e16 years, 32.8 in those aged 0e5 years and 42.1 in those aged 0e2 years.3[III] UK data for children seen at hospital with pneumonia (clinical findings and chest x-ray) in 2001e2 (n¼750) from a prospective population-based study in 13 hospitals in the north of England are remarkably similar with overall incidence rates of 14.4 per 10 000 in children aged 0e16 years per annum and 33.8 for those aged <5 years. Rates of those admitted to hospital were less at 12.2 (11.3e13.2) in children aged 0e16 years and 28.7 (26.2e31.4) in those aged 0e5 years.4[II] A population-based study performed in Kiel, Germany from 1996 to 2000 of children (n¼514) with severe (ie, hospitalised) pneumonia (clinical assessment plus chest x-ray in 96.1%) included children with comorbidities (22.8%) and almost certainly what in the UK would be called bronchiolitis.5[II] The overall incidence per 10 000 was 30 in children aged 0e16 years, 65.8 in those aged 0e5 years and 111.3 in those aged 0e1 year. A series of retrospective population-based cohort studies from the same Schleswig-Holstein area of Germany conducted in 1999e2001 from parental interviews at school entry permitted the calculation of population-based incidence of all CAP diag- nosed by physician as 181.1/10 000 in children aged 0e1 year and 150.5/10 000 in those aged 0e5 years.6[III] Further estimates of pneumonia incidence can be obtained from the PRI.DE (Paediatric Respiratory Infection in Germany) study.7[II] This prospective cohort study was designed to repre- sent the German population of children aged <3 years and included children with lower respiratory tract infection (including pneumonia, wheeze, bronchitis, bronchiolitis and croup) presenting to primary or secondary care from 1999 to 2001. A total of 2386 children were seen as outpatients (2870/ 10 000 population, 95% CI 2770 to 2970) and 114 were given a clinical diagnosis of pneumonia (137/10 000). In addition, 2924 inpatients (294/10 000 population, 95% CI 284 to 304) were included in the study with 1004 given a clinical diagnosis of pneumonia (101/10 000). The incidence of all-cause and pneumococcal pneumonia in children aged <2 years and pneumococcal pneumonia in chil- dren aged 2e4 years decreased in the USA after pneumococcal vaccination (PCV) became universal.8[