PCAP GUIDELINES

Etiology
Outpatient and in-patients: bacterial > viral
For bacterial: Streptoccocus pneumoniae> H.
influenzae> Mycoplasma sp.> Chlamydia sp.

Risk Classification
PCAP A
Minimal

PCAP B
Low

PCAP C
Moderate

PCAP D
High

Co-morbids

None

Compliant
Caregiver

None

None

Ability to
Follow up

None

None

None

Mild

Moderate

Severe

Yes

Yes

No

No

> 11 months

> 11 months

< 11 months

< 11 months

> Or = 50

> 50

> 60

> 70

1-5 yrs

> Or = 40

> 40

> 50

> 50

> 5 yrs

> Or = 30

> 30

> 35

> 35

Variables

Dehydration
Feeding
Age
RR 2-12 mos

PCAP C
Moderate

PCAP D
High

Intercostal/
subcostal

Supraclavicular

Head bobbing

Cyanosis

Variables

PCAP A
Minimal

PCAP B
Low

Retractions

Grunting

Apnea

Sensorium

Awake

Awake

Complications
Action

OPD

OPD

Follow up at
end of
treatment

Follow up
after 3 days

Irritable

Lethargic/
stuporous/
comatose

Admit to
wards

Admit to ICU
Refer to
specialist

Diagnostics
No diagnostic aids initially requested for PCAP
A or B managed on an outpatient basis
Routine exams for PCAP C or D:
CXR PAL
WBC count
CS: blood (for PCAP D), pleural fluid, ETA upon
intubation
Blood gas/O2 sat

Diagnostics
Sputum CS for older children
ESR and CRP are not routinely requested

Predictors of bacterial pathogen

Clinical prediction using a bacterial
pneumonia score
BPS 4 ~ (+) bacterial pathogen in hospitalized
patients 1 month 5 years

Probable organisms acc. to age

Increase age, higher chance of bacterial pathogen,
increasing frequency of atypical organism

Decreased breath sounds

Treatment
Antibiotics are recommended in:
1. Patients classified as either PCAP A or B and is:
(a) beyond 2 years of age; or (b) having high
grade fever without wheeze
2. Patients classified as PCAP C and is: (a) beyond 2
years of age; (b)having high grade fever without
wheeze; (c) having alveolar consolidation in chest
x-ray; (d) or having WBC count > 15,000
3. Patients classified as PCAP D

Treatment
Empiric treatment (bacterial etiology):
PCAP A or B w/o previous antibiotic: Amoxicillin
45 mg/kg/day in 3 divided doses x 3 days (min)
Macrolide if w/ hypersensitivity of amoxicillin
Other regimens: Co-trimoxazole, azithromycin,
erythromycin, co-amoxiclav, clarithromycin

PCAP C w/o previous antibiotic and has complete

immunization against Hib: Penicillin G 100,000
u/kg/day
Oral amoxicillin in patients who can tolerate feeding
(comparable to parenteral penicillin)

Treatment
Empiric treatment (bacterial etiology):
PCAP C w/o Hib immunization: IV ampicillin 100
mg/kg/day in 4 divided doses
Monotherapy (parenteral ampicillin) or combination
therapy (IV penicillin + chloramphenicol) in patients
who cannot tolerate feeding
Other regimens: Amoxicillin/sulbactam, cefuroxime,
chloramphenicol

PCAP D: consult a specialist

Treatment
If CA-MRSA suspected, refer immediately to
the appropriate specalist.
Strategies in clinical management of MRSA:
Follow antibiotic susceptibility based on culture
studies
Vancomycin remains to be the 1st line therapy for
severe infections possibly caused by MRSA
CA-MRSA were more likely to be synergistically
inhibited by vancomycin + gentamicin vs.
vancomycin alone

Treatment
Initial treatment (viral etiology):
Ancillary treatment
Oseltamivir 2 mg/kg/dose BID x 5 days may be
given for laboratory confirmed influenza

Response to antibiotics
Decrease in respiratory signs (i.e. tachypnea)
and defervescense within 72 hours after
initiation of antibiotic FAVORABLE
Nonsevere: RR>5 bpm slower than baseline
Severe: defervescense, decrease in tacypnea &
chest indrawing, increase in O2 sat & ability to
feed within 48 hours

Persistence of symptoms beyond 72 hours

after initiation of antibiotics RE-EVALUATE

Response to antibiotics
Improved: RR < age-specific range without
chest indrawing or any danger signs (central
cyanosis, inability to drink, abnormally sleepy
or convulsions)
Treatment failure
Same: RR > age-specific range WITHOUT chest
indrawing or any danger signs
Worse: Developed chest indrawing or any of the
danger signs

Response to antibiotics
If a patient w/ PCAP A or B is not responding
to antibiotics w/in 72 hours, consider:
Change the initial antibiotic; or
Start an oral macrolide; or
Re-evaluate diagnosis

Causes of treatment failure: co-infection w/

RSV, non-adherence to treatment

Response to antibiotics
If a patient w/ PCAP C is not responding to
antibiotics w/in 72 hours, consider:
Penicillin resistant Strep pneumoniae; or
Presence of pulmonary or extrapulmonary
complications; or
Other diagnosis

Causes of treatment failure: antibiotic

resistance, clinical sepsis, progressive
pneumonia, mixed infection

Response to antibiotics
If a patient w/ PCAP D is not responding to
antibiotics w/in 72 hours, consider:
Immediate re-consultation w/ a specialist

Response to antibiotics
Switch from IV to oral 2-3 days after initiation
of antibiotics recommended if:
Responding to the initial antibiotic therapy
Able to feed w/ intact GI absorption
Without pulmonary or extrapulmonary
complications

Switch from 3 days of IV ampicillin to 4 days of

amoxicillin (preferred) or cotrimoxazole

Ancillary treatment
Oxygen and hydration if needed among
inpatients
Cough preparations, chest physiotherapy,
pNSS nebulization, steam inhalation, topical
solution, bronchodilators are not routinely
used
A bronchodilator may be used if with
wheezing

Prevention
Pneumococcal and Hib vaccination
Zinc supplementation may be administered to
prevent pneumonia
Handwashing using antibacterial soaps
Breastfeeding