Is it COVID-19 or CAP? A look at diagnostic decisions and treatments for 2021-2022

Between the subtle differences between viral and bacterial pneumonia and the demands or beliefs of certain parents can make an accurate diagnosis of community-acquired pneumonia (CAP) more difficult.

“She needs the pink medicine. I know it will work.” These are often the first words we hear even before gathering the history and performing the exam, from the parent of a child presenting with a cough, fever, somewhat irritable, and not sleeping at night (parents are not sleeping either!). Thus, the immediate demand for the ‘pink medicine.’ Dr. Jane M. Carnazzo’s article, “How to correctly diagnose and treat community-acquired pneumonia,”describes the presentation of subtle differences between viral and bacterial pneumonia that causes stress among providers as the decision to treat for bacterial versus viral is a major concern. We have all been educated about the judicious use of antibiotics and antibiotic stewardship to prevent bacterial resistance and adverse side effects when antibiotics are prescribed for viral presentations. Thus, the parent who comes to the practice with the intent of receiving the ‘pink medicine’ presents a communication challenge to providers.1 In 2014, the Commissioner for Public Health in Connecticut sent a ‘Antibiotic Stewardship: Call to Action’ letter to all providers in Connecticut. The Commissioner asked providers to speak frankly with patients (parents) about the need for antibiotics; refer to evidence-based, clinical practice guidelines before prescribing; and talk to colleagues and pharmacists about the judicious use of antibiotics.2 The Centers for Disease Control and Prevention (CDC) presents a map of the numbers of antibiotics prescribed by each state. The national outpatient antibiotic prescriptions rate was 185 prescriptions of penicillins (amoxicillin) per 1000 population in 2018. In addition, the total outpatient antibiotic prescriptions dispensed in 2018 was 60.6 million.3 These data provide compelling evidence that pediatric and adult providers need to use critical thinking diagnostic skills when making the diagnosis of community-acquired pneumonia (CAP), viral versus bacterial, as Dr. Carnazzo recommends.

Clinical Practice Guidelines for CAP

The Pediatric Infectious Disease Society and the Infectious Disease Society of America published the clinical practice guideline (CPG) for CAP in infant and children in 2011.4 Although it is time to update these guidelines, they remain the standard of care for treating CAP in infants older than 3 months of age, as well as children and adolescents. For infants and children who do not present with respiratory distress, these guidelines inform the assessment and diagnosis for children with CAP. First, testing for viral pathogens should be performed in outpatient settings. During the upcoming fall and winter months in 2021-2022, testing for COVID-19, influenza, respiratory syncytial virus (RSV), and other viral pathogens is appropriate, to make the correct diagnosis of a viral pathogen, or viral versus bacterial pneumonia. A complete blood count, erythrocyte sedimentation rate, or C-reactive protein testing are not needed per the guideline, unless clinical judgement is such that these laboratory results would be beneficial to establishing the diagnosis, consistent with Dr. Carnazzo’s recommendations. Also, consistent with Dr. Carnazzo’s article, chest X-rays are not recommended unless, clinical judgement for a particular child outweighs the CPG recommendation for management.

It is recommended to obtain a pulse oximetry reading for each infant, child, and adolescent who presents with a potential diagnosis of CAP.4 The readings may be helpful in determining whether the child can be managed at home or must be referred to the hospital.

If CAP is suspected to be bacterial in origin, then amoxicillin remains as first line therapy for previously healthy, immunized infants and young children. The CPG also provides guidance on which antibiotics to use for specific age children presenting with bacterial CAP.4 Following this guidance is important as part of antibiotic stewardship, as pediatric providers make every effort to practice safe medicine, but also to reduce the incidence of antibiotic resistance and adverse side effects when antibiotics did not need to be prescribed.

The fall-winter season is also the time to message or call all of your patients to provide the influenza vaccine to eligible infants, children, and adolescents in your practice to reduce the incidence of the disease. In addition, it is also time, to fully support the COVID-19 vaccine for all children aged older than 12 years. If, in the next few weeks, the US Food and Drug Administration completes the data analysis for children between 5 and 11 years of age, and makes the recommendation for administrating the COVID-19 vaccine, providers should also support it and make arrangements for administration of the vaccine to this population.

One additional protection children have against COVID-19, influenza, RSV, and CAP is mask wearing. For young children, wearing masks has become routine. For older children, parental and provider support goes a long way in following this strong recommendation. Let’s reap the benefits of the wearing masks as a protective strategy and have an uneventful, more normal 2021-2022 fall and winter season. We can all benefit from normalcy – and while we are at it – let’s acknowledge the strength of the parents, grandparents, and all caregivers who raising children during this pandemic! They deserve our praise and our support.

References

1. Centers for Disease Control and Prevention. Antibiotic prescribing and use. Reviewed July 15, 2021. Accessed October 11, 2021. https://www.cdc.gov/antibiotic-use/index.html

2. Mullen, J. Office of the Commissioner: Antibiotic stewardship: A call to action. Published April 9, 2014.. Accessed October 11, 2021. https://www.cdc.gov/antibiotic-use/community/~local/modules/programs-measurement/Call-to-Action-Letter-CT-508.pdf

3. Centers for Disease Control and Prevention. Antibiotic resistance & patient safety portal - penicillins. Accessed October 11, 2021. https://www.cdc.gov/antibiotic-use/community/~local/modules/programs-measurement/Call-to-Action-Letter-CT-508.pdf

4. Bradley J, Byington C, Shah S, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases. 2011;53(7):e25-e76. doi:10.1093/cid/cir531