Guidelines with Gabi:
March 10, 2023
On this Talking Pediatrics episode, Dr. Gabi Hester will discuss all-things pneumonia with pediatric hospitalist and Kid Expert, Dr. Courtney Herring. Their discussion will include the latest guidelines around antibiotic selection, shorter duration of therapy, and not needing blood cultures in most patients.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the kid experts where the complex is our every day. Each week we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. There isn’t a clinician among us who hasn’t treated a child with pneumonia. But how do we know that we’re following the latest guidelines around antibiotic selection, duration of therapy, and how to approach evaluation for pediatric pneumonia? On this episode of Talking Pediatrics, Dr. Gabi Hester will discuss all things pneumonia with pediatric hospitalist and kid expert, Dr. Courtney Herring.
Speaker 2: Welcome to guidelines with Gabby.
Dr. Gabi Hester: There are many potential causes for cough and trouble breathing in kids. With the nationwide surge of patients suffering from RSV bronchiolitis this year, it might be easy to lose track of another cause, pneumonia. Despite having vaccines that can prevent some types of bacterial pneumonia as well as effective antibiotic options, pneumonia is the single largest infectious cause of death in children worldwide. In 2019, pneumonia killed almost three quarters of a million children under the age of five. Today we’ll be speaking with one of our kid experts. Dr. Courtney Herring is a pediatric hospitalist at Children’s Minnesota and the lead of a new clinical practice guideline for community acquired pneumonia at our organization. Welcome, Courtney.
Dr. Courtney Herring: Oh, hey, Gabi. Thank you for the invite.
Dr. Gabi Hester: Well, thanks for coming. And let’s start by level setting a little bit. In basic terms, what exactly is pneumonia and what is happening in the lungs of these kids?
Dr. Courtney Herring: Obviously a great starter question. So pneumonia really has been historically defined as an infection of the lung parenchyma or the tissue of the lung. But I would actually say rather than looking at it as a single disease, I think as healthcare professionals, you really should remember that pneumonia is an umbrella term for a group of syndromes caused by a variety of organisms resulting in varied manifestations and sequelae. And though I think most importantly there is no universal presentation of pneumonia that is like pathognomonic over other various lower respiratory tract conditions such as asthma, bronchiolitis is a highlight of our pediatric population and even pneumonitis, this can make the clinical diagnosis challenging. So really it’s the focus of common signs, symptoms, physical exam findings, and importantly matching that patient’s history leading you to the clinical diagnosis of pneumonia.
Dr. Gabi Hester: You mentioned that pneumonia is really an umbrella term and that there are various causes for it. Can you talk a little bit about some of the different causes we would see in our pediatric population?
Dr. Courtney Herring: Pathogen causes of pneumonia run the gamut of bacteria, fungi and viruses with a significantly heavy dosing of viral causes in our under five-year-old patients. I would say typical bacterial pathogens that cause community-acquired pneumonia include streptococcus pneumoniae, otherwise known as pneumococcus, haemophilus influenzae usually non-typable due to our PCV13 vaccine for our Hib, or haemophilus influenzae B already being protective, and moraxella catarrhalis as a third top. And I say just as the advent of novel diagnostic technologies, bio respiratory pathogens are increasingly being identified as frequent ideologies of community-acquired pneumonia.
Dr. Gabi Hester: So you led this new guideline that was developed at Children’s Minnesota. Tell me a little bit about why. What was the need that you were seeing here at our organization that prompted this?
Dr. Courtney Herring: The need truly stemmed from opportunities presented by amazing research that has been published in pediatric health in the past five or so years focused on diagnostic utility, antibiotic stewardship, and also utilization on the care continuum. I think when you look at our professional societal guidelines and I call out our IDSA or Infectious Disease Society America, that guidance is over 10 years old and in fact they’ve actually archived their pediatric community acquired guidelines at this time awaiting new guidance from them, which we look forward to. So really it’s just about limiting antibiotic use to the shortest possible effective duration which is critical to reducing adverse effects of antibiotic treatment as well as spread of antimicrobial resistance.
Dr. Gabi Hester: Now before we dig into the recommendations, whenever I am teaching residents or students about sort of how to use a guideline, I always encourage them to look at inclusion criteria, exclusion criteria and really to think through if this particular guideline can be applied to that particular patient. Can you tell me a little bit about some of the exclusion criteria for the guideline before we get into the detail of the recommendations?
Dr. Courtney Herring: Absolutely. The intent of the guideline is always something to take home first. So the exclusion criteria for our community acquired pneumonia uncomplicated guidelines is with focus in an age of over two months to 18 years old. If you are under two months in that neonatal phase and/or you’re an adult patient, those are excluded in these guidelines, which I hope makes sense to our audience here. And then other big players are if you have significant high-risk lung disease such as cystic fibrosis or you are immunosuppressed or have immunodeficiencies. Other mechanical risks are if you have tracheostomy dependence or ventilator dependence. And then historical definitions such as high-risk aspiration and/or long convalescence in hospitals, raising your risk of different pathogens are important to note.
Dr. Gabi Hester: So if I’m out in the clinic or in the ED and I’m seeing a patient that I think has pneumonia, what are some of the things I should do for that patient? And then I guess also what not to do for the workup?
Dr. Courtney Herring: Yeah, I feel like this is our common adage, Gabi, which is less is more. So if the patient is not meeting inpatient admission criteria such as true hypoxia, defined as having oxygen saturation stately under 90%, increased workup breathing or even failed outpatient therapy, then the general recommendation is to give anticipatory guidance and forego labs and chest X-rays.
Dr. Gabi Hester: Just to reiterate that, no chest X-rays. Tell me a little bit about that.
Dr. Courtney Herring: Chest X-rays, which absolutely can be helpful in the right clinical contexts, when you’re looking at community acquired pneumonia, it truly is a clinical diagnosis as I’ve previously mentioned. And so there is quite a bit of looking across national guidance of the reliability of chest X-rays. There is quite a bit of variability in the readings of those, whether it is from the provider themselves in clinic or by actually radiologists. And so I think when you look at the bigger picture, the utility and the mechanism of making management plans based on a chest X-ray really is not near as marked as most people may think in our setting in health care.
Dr. Gabi Hester: So it sounds like reliance really on my history and physical examination.
Dr. Courtney Herring: Agreed a hundred percent.
Dr. Gabi Hester: Now let’s talk a little bit about labs because I know that you as a hospitalist, I’m sort of used to seeing these kids coming in already having gotten a blood culture or a CBC with differential, even sometimes a C-reactive protein. What is the guidance on this new recommendation around blood testing?
Dr. Courtney Herring: As alluded to it in the outpatient setting, which of course carries a fair amount of the burden of community-acquired pneumonia, the recommendations is pretty minimalistic. So unless you have concerns that a patient needs an escalation of care, such as being moved to an emergency department for further evaluation and management and or inpatient services, really we’re limiting our recommendations to anticipatory guidance, and understanding the history depending on the patient is highly viral in nature that we would not need any further testing for that.
Otherwise for inpatient use or emergency department use, what we really look at is dividing and conquering if a patient comes in who looks very ill appearing such like with our sepsis guidelines. That really does differentiate how you look at how you review that patient’s need and their risk. So for us, I always call out blood cultures, which I know is a big thing you and I have talked about in the past. Multiple studies reviewing utility of blood cultures in the management of community acquired pneumonia have been accomplished.
And I’ll call out one specific, that was a great article in pediatrics in 2017 by Neumann Hall looks at it all, really looking at blood culture utility among hospitalized children with community acquired pneumonia. So it was a five year retrospective cohort study. They reviewed over 7,500 non-ICU hospitalized children. And in that group alone, they found that a positivity rate of blood cultures was only 2.5%. And then when they actually went beyond that and looked at the prevalence of bacteremia positive blood cultures among severe or complicated pneumonias, it was only 4.2%. And once you break down the utility, there is different stratification of those complicated pneumonia patients. When you look at management options, we really are doing a great job in the front hand of knowing how to treat this without needing these further diagnostics such as blood cultures or other differentiating lab results.
Dr. Gabi Hester: So to summarize, we don’t need to get blood cultures unless you have a patient who’s critically ill or they have a complicated pneumonia like an empyema. Is that correct?
Dr. Courtney Herring: Correct.
Dr. Gabi Hester: So just to play devil’s advocate here, which you know which side of the fence I land on, so I appreciate when we don’t get blood cultures. That’s where I land. But let’s just pretend. What’s the harm in getting a blood culture?
Dr. Courtney Herring: Well, I think it’s actually looking globally at the patient. So confidence that blood cultures will not make the difference in management for uncomplicated pneumonia, I think the backflow rewards include reducing medical trauma to patients, not causing increased length of stays, which is huge in regard to utilization of hospital resources, as we all have really come out of a pretty significant capacity issue across our pediatric healthcare systems. These all come with great cost and I truly mean really psychologically as well as financially. So there are a lot of gains by really looking at these recommendations not only for patient safety but also in regards to utilization across healthcare.
Dr. Gabi Hester: And you mentioned increased length of stay. If I recall that article on pediatrics as well as another fairly similar study done in Spain found that just having a blood culture obtained in the setting of community acquired pneumonia, those children had an increased length of stay of almost a full day. I think it was like 0.9 days in both of the studies actually. So even just obtaining a blood culture might change your mindset of wanting to, oh, we got to watch the blood culture to make sure it’s negative before we send them home. That’s probably one of the biggest changes I’ve seen in recommendations in the last 10 years around pneumonia is really to avoid getting blood cultures because of those potential factors and costs, but also the fact that it doesn’t actually help us make decisions.
Dr. Courtney Herring: And you broke down those articles absolutely accurately. About 0.9 days length of stay change with a blood culture.
Dr. Gabi Hester: What kid wants to be poked if they don’t need to and what family wants their child to go through that? So I think there’s certainly a patient experience lens here that we can apply as well. Let’s shift a little bit to treatment. Tell me a little bit about the basic antibiotic strategy.
Dr. Courtney Herring: Again, it’s trying to find the right drug for the right patient with the right bug and it’s being oversimplified to a certain level. So what we have found, and I will go back and actually cite the Neumann article around blood cultures, when they had the 2.5% positive blood cultures in their cohort, they of course looked at those more specifically. And I think the call out here is great. 80% of the positive blood cultures were pneumococcal species. And out of those pneumococcal species, over 80% of those, almost 90% were penicillin susceptible.
And why I actually quote this is for a little bit more nuance for all of my academics is that this study actually started before PCV13 came into action. This initiated in the era PCV7 and then finished after a couple years after the onset of PCV13 vaccinations. And it really builds confidence that we still are not in the realm of significant invasive disease and resistant disease, that we really are still in this susceptible disease pattern of pneumococcus, which still is going to be a leading cause of bacterial community-acquired pneumonia. So that speaks to the idea that antibiotics in these penicillin family such as amoxicillin and ampicillin are absolutely first line and we should have as providers have really good confidence in that.
Dr. Gabi Hester: So what about azithromycin? I remember sort of doing my pediatrics training and hearing about if you have a school-age patient with pneumonia to consider like an atypical pneumonia and using azithromycin. Where is the literature on that these days?
Dr. Courtney Herring: Well, I’ll call out that our recent guideline specifically reports out that we are not recommending azithromycin in generally even our uncomplicated community acquired pneumonia hospitalized children. This is partly based on a large observational study that showed no benefit of empiric combination therapy with a macrolide, which is referring to azithromycin plus a beta-lactam antibiotic for. And when they compared that to a monotherapy beta-lactam in hospitalized children and on the nuanced with radiographically confirmed community-acquired pneumonia, that this really served no assistance with length of stay, free hospitalizations or recovery follow up.
So I think this was really a great demonstrative study of looking at the utility actually of azithromycin in at least our hospitalized patients. And I will one up that and say the conversations I’ve had with our antibiotic stewardship team, there is another study that really looks at lack of benefit of macrolide therapy or azithromycin in subgroup of hospitalized children with atypical bacteria detected. So even when it was detected, there is some question that do all patients with atypical pneumonia actually need full therapy?
Dr. Gabi Hester: Wow. So sounds like more to come on the story a little bit there?
Dr. Courtney Herring: Yeah, TBD, but definitely at this juncture we’re outside of clinical context. We are not recommending azithromycin in outpatient and or inpatients at this time.
Dr. Gabi Hester: Continuing on the theme of shaking up old dogmas, we’ve already said no more blood cultures. We’ve said no more azithromycin. So there’s also been sort of the dogma around seven to 10 days of antibiotic therapy and what does the new guidelines say?
Dr. Courtney Herring: It is been exciting to talk about duration of therapy, and with just an amazing amount of research behind it and evidence to really help us propel this forward. So I know I’m supposed to be brief, but oh, I could talk about this all for like an hour. But the bottom line is our current recommendations are in our outpatient setting. If you are looking to utilize antibiotics, that you are using five days of therapy in our outpatient service. And then as an inpatient, it’s a five to seven day course depending on clinical context while hospitalized.
Dr. Gabi Hester: And how did some of those recommendations come about? I presume that there are some studies. Can you tell us about one of them?
Dr. Courtney Herring: As you alluded to, there is several studies demonstrating non-inferiority of short versus long course antibiotics, intravenous and oral versus parenteral or IV for uncomplicated community-acquired pneumonia. One, I will say from the inpatient side, there’s a randomized control study by Macallan et al, actually published just this past year in 2022, and looked at children three months to five years of age for hospitalized children and showing no superiority for long course being 13 to 14 days of antibiotics versus five to six day courses. So that really was really great because it drew a very concrete line between long and short course therapy, which has been a little bit more difficult in some of the historical data.
But I really would like to focus on our outpatient who really does handle the burden of community-acquired pneumonia. So there’s a great investigation in JAMA Pediatrics that examined whether short course antibiotic therapy was in fear to the “standard” 10-day course of antibiotics. And they looked at ages, for transparency, looked at ages six months to 10 years in the outpatient setting. Two centers, blinded, non-inferiority randomized controlled trial ended up having 300 included patients. And what they found was five days of amoxicillin versus 10 days of amoxicillin was comparable. Comparable clinical cure rates of 89% versus 91% heavily suggested that short course antibiotics are just as good. And your downstream risks are mitigated in regards to adverse drug effects and antimicrobial resistance patterns. So really full circle positive results here.
Dr. Gabi Hester: Before we wrap up, I do want to ask about sort of the elephant of the room. Here we are in 2023 now. Is there any difference in management to kids with COVID-19? COVID-19 being something that is now sort of part of our milieu, if you will.
Dr. Courtney Herring: In currents, I don’t think we’re ready to call COVID-19 in our bucket of community-acquired pneumonia, even though I feel like we have felt it’s been a century, it’s really only been three years and we’re still learning a ton about the pathophysiology and management utility, whether it’s proactive utility and prophylaxis and/or in actual inpatient management. So I would recommend in this current state reviewing our updated Children’s Minnesota COVID-19 guidelines specifically for the treatment of COVID-19.
Dr. Gabi Hester: And I do want to point out as well that the work around this new guideline here at Children’s Minnesota was actually part of a larger collaborative with the American Academy of Pediatrics. Just so people don’t think we’re just going rogue and going off on our own. Can you briefly speak about the basic collaborative and what that was?
Dr. Courtney Herring: So the basic collaborative is standing for better antibiotic selection in children, really highlighted a couple of main diagnoses that we see across healthcare, but specifically in children. One is skin and soft tissue infections, urinary tract infections. And then for our site at Children’s Minnesota, our third and last guidance in this group was for community-acquired pneumonia. And the focus of this group was heavily on antibiotic stewardship, so once again, choosing the correct antibiotic for the correct patient and at the same time duration of therapy. And so really two high level metrics followed throughout over a hundred different sites across the nation, got a wonderful, wonderful data over the two and a half years of this project. And as one of the contributors, I will say we’re not doing too bad, Gabi. We’re not doing too bad.
I think we have a lot of work. You are intimately understanding that we have a lot of work to do at Children’s Minnesota, but we’re doing really well in a lot of the realms of attempting to move forward change and optimize patient healthcare in regards to antibiotic stewardship. So I would say that basic trial has come to an end and it’ll be published later this year. I’m excited to see that. But in regards to where we’re in currently, we are going to continue to work. This is an ever evolving optimization of how we treat our patients, how we look at healthcare, and not only looking at what we actually give our patients and how we treat our patients, but also the mental and emotional part of how the patient experience matters.
And so I know that we are committed to that at Children’s Minnesota and I’m just grateful to be a part of that. So more to come. And I really hope that if there are any questions regarding this guideline at Children’s, much less anyhow, I am always available to hopefully be a sounding board if you have any questions.
Dr. Gabi Hester: Well, Courtney, thank you so much for that and for joining us today. And I think more broadly, thank you so much for really diving into a lot of this important work at Children’s Minnesota and really helping to share your knowledge with the community.
Dr. Courtney Herring: Well, I would say, Gabi, you’re one of my biggest mentors. You have started a lot of the most beautiful work we do at Children’s in regards to the quality of care that we provide for children in across the Midwest, but specifically in Minnesota. It’s a privilege to work with the people I get to work with every day.
Speaker: Take home points.
Dr. Gabi Hester: Number one, viruses are the most common cause of pneumonia in children less than five years of age. Number two, no blood cultures. Lab studies including blood cultures, are not recommended for most patients with pneumonia unless they have empyema or are critically ill. Number three, amoxicillin is the first line antibiotic for most cases of pediatric pneumonia. Number four, recommended treatment duration is five days for outpatients or five to seven days for most inpatients with pneumonia.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amie Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.