DRAFT JULY 2017 TASK 2016 pcap CPG

1 An Official Publication of the Philippine Academy of Pediatric Pulmonologists, Inc. PAPP PERSPECTIVE 3rd PAPP Update [2016] in the Evaluation and management of Pediatric community - acquired pneumonia 2016 PAPP Task Force on pCAP2 PHILIPPINE ACADEMY OF PEDIATRIC PULMONOLOGISTS, Inc. [PAPP, Inc.] 2016 PAPP Task Force on pCAP: 3rd PAPP Update [2016] in the Evaluation and management of Pediatric community - acquired pneumonia . All rights reserved. Publication and request for permission to reproduce should be obtained from the Philippine Academy of Pediatric Pulmonologists, Inc., Room 4, 4/F Philippine Pediatric Society Building, 52 Kalayaan Avenue, Barangay Malaya, Quezon City 1100 Philippines. Telefax Number [632] 3328855. Email address: Website: PHILIPPINE ACADEMY OF PEDIATRIC PULMONOLOGISTS, Inc. [PAPP, Inc.]

2 ] 2016-2017 Board of Directors Mary Therese M. Leopando, MD FPPS FPAPP President Mary Ann F. Aison, MD FPPS FPAPP Vice president Regina M. Canonizado, MD FPPS FPAPP Secretary Nepthalie R. Ordonez, MD FPPS FPAPP Treasurer Anna Marie S. Putulin, MD FPPS FPAPP Director Amelia G. Cunanan, MD FPPS FPAPP Director Lydia K. Chang, MD FPPS FPAPP Director Clara R. Rivera, MD FPPS FPAPP Immediate past president 2016 PAPP Task Force on pCAP Cristan Q. Cabanilla, MD FPPS FPAPP Chair Emily B. Gaerlan-Resurreccion, MD FPPS FPAPP Secretary Vivian A.

3 Ancheta, MD FPPS FPAPP Member Gari D. Astrologio, MD DPPS DPAPP Member Janet C. Bernardo, MD FPPS FPAPP Member Alfredo L. Bongo Jr, MD FPPS FPAPP Member Janet Myla Q. Bonleon, MD FPPS FPAPP Member Lydia K. Chang, MD FPPS FPAPP Member Edward A. Chua, MD DPPS DPAPP Member Julie Iris C. Clapano, MD FPPS DPAPP Member Amelia G. Cunanan, MD FPPS FPAPP Member Beverly D. de la Cruz, MD FPPS DPAPP Member Anjanette R. de Leon, MD FPPS FPAPP Member Yadnee V. Estrera, MD DPPS DPAPP Member Jean Marie E.

4 Jamero, MD DPPS DPAPP Member Arnold Nicholas T. Lim, MD DPPS DPAPP Member Grace V. Malayan, MD FPPS FPAPP Member Beatriz Praxedez Apolla I. Mandanas, MD DPPS DPAPP Member Raymund Anthony L. Manuel, MD DPPS DPAPP Member Vicente Carlomagno D. Mendoza, MD FPPS DPAPP Member Doris Louise C. Obra, MD FPPS FPAPP Member Catherine S. Palaypayon, MD DPPS DPAPP Member Cynthia Theresa M. Rimando, MD FPPS DPAPP Member Ernesto Z. Salvador, MD DPPS DPAPP Member Marion O. Sanchez, MD FPPS FPAPP Member Josy Naty M. Venturina, MD DPPS DPAPP Member Rozaida R. Villon, MD FPPS FPAPP Member Nilyn Elise O.

5 Ygnacio, MD DPPS DPAPP Member Dahlia L. Yu, MD DPPS DPAPP Member3 CONTENTS Preface Introduction Methodology Overview Disclaimer Update Recommendations Clinical Questions Background: 2nd PAPP Update [2012] Recommendations 3rd PAPP Update [2016] Recommendations Summary of Evidence Bibliography Appendix4 PREFACE The Philippine Pediatric Society in 2004 spearheaded the publication of the Clinical Practice Guideline in the Evaluation and management of Pediatric community - acquired P n e u m o n i a [pCAP]. Because of the important, unresolved issues and concerns on pCAP in the following years, the Philippine Academy of Pediatric Pulmonologists [PAPP] drafted the first Update in the Evaluation and management of pCAP in 2008.

6 Revisions on several recommendations b a s e d on recent evidences from local and foreign literature were published in the second PAPP Update in 2012. The PAPP Task Force on pCAP in 2016 felt the need to come up with the third Update on pCAP to include new developments on recommendations in the evaluation and management of childhood pneumonia . It is our hope that this recent update will assist and guide clinicians in the management o f pCAP thereby improving the quality of health care for Filipino children. Mary Therese M. Leopando, MD FPPS FPAPP President Philippine Academy of Pediatric Pulmonologists, INTRODUCTION Similar to the 2008 and 2012 PAPP Updates in Pediatric community - acquired pneumonia , the 2016 PAPP Update is anchored on a framework that is primarily intended for individual clinical practice.

7 In reviewing the current body of evidence, such framework has focused on identifying clinically important outcomes for each clinical question, and expressing the impact of harm and benefit of each intervention in numerical values whenever possible. While the former is universal, the latter can be applied on a case-to-case basis irrespective of recommendation. Three limitations of the current update have to be mentioned. First, because of limited funding and logistics, there is failure to include cost-benefit ratio of each diagnostic, therapeutic or preventive intervention [which is important considering that most financial transactions are out-of-pocket in most resource-limited s it uat ions ]. There is similar failure to address the issue of availability of interventions in the local setting [which is equally important considering that some of these are only available in selected medical centers nationwide].

8 Second, there is a considerable lack of epidemiologic data, and patient-outcome oriented and knowledge-gap directed body of researches reported in the local setting, both of which could have provided basis for stronger recommendations. And third, there is currently no neutral national clearing house outside of PAPP that could have provided initial guidance and subsequent peer review in developing the guideline update. In preparation for the 4th PAPP Update [2020], these limitations, which potentially can lead to barriers in Implementation, have to be addressed to narrow the policy-practice gap among local practitioners. Key differences between the 2nd and 3rd Updates are summarized below. SECTION KEY DIFFERENCES 2012 2016 A. Methodology 1. Microbial etiology Virus, bacteria and Mtb Virus and bacteria 2.

9 Geographic distribution of Task force membership MetroManila MetroManila, MetroCebu and MetroDavao 3. Literature review Jan 2008 to Dec 2011 Jan 2012 to Dec 2016 4. Definition of level of evidence and grading of recommendation Based on Sacket DL, Straus SE: Evidence Based Medicine 2000 Developed by the 2016 PAPP Task Force in pCAP 5. Geographic distribution of stakeholders MetroManila Nationwide B. Summary recommendations 1. Appraisal Clinical Question1 1. Predictors to detect radiographic pneumonia a. Higher threshold for Sa02 b. Additional indeces 2. Addition of negative predictors for radiographic pCAP 3. Revised indications for requesting chest xray at initial site-of-care Clinical Question 2 No significant change Clinical Question 3 No significant change Clinical Question 4 1. Addition of lung ultrasound and anaerobic culture as diagnostic tests 2.

10 Removal of diagnostic test for tuberculosis Clinical Question 5 1. Additional test to determine necessity of antibiotic administration 2. No recommendation for pCAP A or B 2. Therapeutic approach Clinical Question 6 No significant change Clinical Question 7 Addition of zanamivir Clinical Question 8 Addition of deifinition of clinical stability Clinical Question 9 No significant change Clinical Question 10 No significant change Clinical Question 11 Zinc may be beneficial 3. Preventive strategies Clinical Question 12 Zinc may not be beneficial Cristan Q. Cabanilla, MD FPAPP FPPS Chair 2016 PAPP Task Force on pCAP6 METHODOLOGY OVERVIEW A. Scope The 3rd PAPP Update in the Evaluation and management of Pediatric community - acquired pneumonia [2016] is limited to clinical recognition of radiographic community - acquired pneumonia , identification of appropriate and practical diagnostic procedures, and initiation of rational management and preventive measures in an immunocompetent patient aged 3 months to 19 years.