Community acquired pneumonia in children: Outpatient treatment and prevention

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Saavedra" "apellidos" => "Lozano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "j" "identificador" => "aff0050" ] ] ] 10 => array:2 [ "colaborador" => "representing the Sociedad Española de Infectología Pediátrica (SEIP), Sociedad Española de Neumología Pediátrica (SENP) and the Comité Asesor de Vacunas de la Asociación Española de Pediatría (CAV-AEP)" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "1" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:10 [ 0 => array:3 [ "entidad" => "Infectología Pediátrica e Inmunodeficiencias, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Grupo de Investigación IBIMA, Departamento de Pediatría y Farmacología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección de Neumología Pediátrica, Servicio de Pediatría, Hospital Universitario Virgen Macarena, Departamento de Farmacología, Pediatría y Radiología, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Neumología Pediátrica y Fibrosis Quística, Servicio de Pediatría, Hospital Clínico Universitario, Universitat de València, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Neumología y Alergia Pediátrica, Servicio de Pediatría, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital San Joan de Dèu, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Sección de Neumología Pediátrica y Fibrosis Quística, Hospital Universitario Vall d¿Hebron, Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Unidad de Enfermedades Infecciosas e Inmunología Clínica, Servicio de Pediatría, Hospital Universitario Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital 12 de Octubre, Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Unidad de Infectología Pediátrica, Servicio de Pediatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonía adquirida en la comunidad: tratamiento ambulatorio y prevención" ] ] "textoCompleto" => "IntroductionCommunity acquired pneumonia (CAP) is the single main cause of child mortality worldwide. It is estimated to be responsible for 1.2 annual million deaths in children under 5 years of age, which accounts for 18% of all deaths at this age, 99% of them in developing countries.<a class="elsevierStyleCrossRef" href="#bib0195">1</a>In developed countries and regions, such as North America, Europe, Oceania and Japan, there are estimated to be up to 2.6 million annual cases of CAP in children under 5 years of age, causing 1.5 million hospitalisations and, approximately, 3000 deaths,<a class="elsevierStyleCrossRef" href="#bib0200">2</a> more than the number of deaths for meningitis.In the last decade, the aetiology, clinical presentation and evolution of CAP in the paediatric population have changed significantly with the introduction of vaccines against pathogens involved in its aetiology (such as Haemophilus influenzae [H. influenzae] type b and Streptococcus pneumoniae [S. pneumoniae]), the better use of antibiotics, as well as other factors which have not yet been explained but are probably associated with independent epidemiological trends.As already explained in the document on the aetiology and diagnosis of CAP agreed by these two paediatric associations,<a class="elsevierStyleCrossRef" href="#bib0205">3</a> the main aetiological agents are viruses and S. pneumoniae. Viruses affect mainly children under 4–5 years of age, while S. pneumoniae affects children of any age. However, in the last 10–15 years the incidence of complicated pneumonias, manifesting as either pleural effusion or necrotising pneumonia, has steadily increased. Changes have also been observed in the age of onset of complicated pneumonias. Where previously it was more frequent in children under the age of 2–3 years, it now predominates in children 2–5 years of age. There has also been a slight increase in the number of cases caused by Staphylococcus aureus (S. aureus), some caused by strains produced by certain virus factors which make them more serious.Paediatricians treating children with CAP<a class="elsevierStyleCrossRef" href="#bib0210">4</a> have access to a huge range of therapies, and in many countries clinical guidelines are not followed.<a class="elsevierStyleCrossRefs" href="#bib0215">5,6</a> Therefore, one of the most ambitious goals of this consensus is to harmonise therapeutic measures against this disease in Spain and improve control measures.<a class="elsevierStyleCrossRef" href="#bib0225">7</a> In this document, based on the scientific information available and the experience of the authors, initial measures are proposed which we believe are more adequate for the therapeutic treatment of CAP. Also, the prevention measures available against CAP in the population of children are summarised. In another document, soon to be published in this journal the therapeutic approach to complicated cases and special circumstances will be presented.Current status of resistances to antimicrobial drugsDrug-resistant bacteria that can potentially cause CAP include S. pneumoniae, S. aureus, Streptococcus pyogenes (S. pyogenes) and H. influenzae type b. In Spain, other causal agents of CAP, such as Mycoplasma pneumoniae (M. pneumoniae) or Chlamydophila pneumoniae (C. pneumoniae), or viruses, are not drug-resistant. M. pneumoniae and C. pneumoniae are usually sensitive to macrolides and the only virus to be treated with antiviral drugs, the flu virus, so far does not present resistance to oseltamivir in our area.The most reliable data on the drug-resistance of the main respiratory pathogens in our area are periodically provided by the multi-centre study known as Sensitivity to Antibiotic Drugs Used in the Community in Spain (SAUCE in Spanish). The latest, published in 2010 as the SAUCE-4 study,<a class="elsevierStyleCrossRef" href="#bib0230">8</a> offers results on sensitivity and resistance according to official cutoff points (CLSI cutoff points). It contains a total of 2559 isolations of S. pneumoniae, 2287 of S. pyogenes and 2287 of H. influenzae, and these are compared to those recorded in the previous 11 years. In summary, the most relevant data are described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>. For S. pneumoniae, as regards sensitivity to β-lactams, currently almost all strains circulating in Spain are sensitive to oral amoxicillin and intravenous penicillin and ampicillin, and also cefuroxime, if we wish to broaden the spectrum. They are all sensitive to cephotaxime. In recent years, the percentage of penicillin-resistant strains (intermediate sensitivity or total resistance) have risen from 60.0% to 22.9%. The proportion of strains with total resistance to oral penicillin (MIC≥2) has decreased drastically from 36.5% to 0.9%. Also, 0% presents total resistance (MIC≥8) for parenteral penicillin and only 0.2% intermediate sensitivity (MIC≥4). There are still high rates of resistance to macrolides (21–25%).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>For H. influenzae, 15.7% are producers of β-lactamases and, therefore, resistant to penicillin, ampicillin or amoxicillin. This percentage has decreased, from the previous level of 25.7%.These data, based on samples from children and adults taken 6–7 years ago, can be combined with the findings of a recent study by Heracles in the Community of Madrid (May 2011–April 2013),<a class="elsevierStyleCrossRefs" href="#bib0235">9,10</a> where 100% of S. pneumoniae strains isolated in children under 15 years old with invasive pneumococci disease outside the central nervous system—including bacteraemia pneumonias and empyema—are sensitive to penicillin and cephotaxime.Adjuvant support treatmentIn children with CAP, antibiotic therapy at times needs to be complemented with other strategies, although this is less frequent in patients not requiring hospitalisation.Children with pneumonia usually feel associated pain (pleuritic, abdominal, headache) and discomfort or pain due to inflammation of upper airways (otalgia, odynophagia). Analgesia is recommended for relief, especially in cases of pleuritic pain, because it interferes with coughing and breathing.<a class="elsevierStyleCrossRefs" href="#bib0245">11,12</a> Paracetamol can be used (15mg/kg/6h; up to a maximum of 75mg/kg/day) or ibuprofen (5–10mg/kg/6–8h). Fever must be controlled with these same agents, as oxygen requirements increase. There is insufficient evidence that mucolytic and cough suppressants are beneficial, and in theory, medications with codeine or antihistamines should not be used in young children.<a class="elsevierStyleCrossRef" href="#bib0255">13</a>Increased effort of breathing and fever increase the requirement for fluids. The ideal way to provide them is orally, in small amounts and frequently.Ambulatory treatment of non-complicated CAP with antibioticsIndication for the use of antibioticsEmpirical treatment of CAP is based on the pathogens most frequently involved. However, one of the most important problems is correct distinction between probable viral aetiology and probable bacterial aetiology. Clinicians tend, mistakenly, to use antibiotics in excess, which leads to an increase in antimicrobial resistances. In patients aged less than 2 years, with mild clinical lower airway manifestations and a history of correct immunisation according to age against H. influenzae type b and S. pneumoniae bacterial aetiology is unlikely.<a class="elsevierStyleCrossRef" href="#bib0260">14</a>Antibiotics are indicated in typical CAP where bacterial aetiology is suspected. In cases of atypical CAP they should only be used in children over 4–5 years old and in certain younger patients if the infection is serious.For treatment under special circumstances (allergy to β-lactams, base disease, immunodepressed, etc.), or patients requiring hospitalisation, more information will be available in the specific document that will be published in a subsequent issue of this journal.Selection of the antibiotic, route, dosage and durationTypical CAPIf it has been decided to initiate ambulatory antibiotic treatment in typical CAP with no criteria for hospital admission, considering that most are caused by pneumococci and that, currently, almost all are sensitive to penicillin and amoxicillin,<a class="elsevierStyleCrossRef" href="#bib0230">8</a> the antibiotic of choice is 80–90mg/kg/day oral amoxicillin, every 8h (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>). This recommendation is consistent with current international guidelines.<a class="elsevierStyleCrossRefs" href="#bib0250">12,15</a> The maximum recommended dose, according to the package leaflet, is 2g every 8h, given the good tolerance of this antibiotic.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>There may be some controversy regarding the recommended dose. Given the good absorption of this drug and its good penetration at a pulmonary level, as well as the low rates of resistances of S. pneumoniae, doses of 40–50mg/kg/day will suffice in most cases. This consensus recommends, however, higher doses (80–90mg/kg/day) due to the following reasons:<a class="elsevierStyleCrossRef" href="#bib0270">16</a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">–The use of low doses (40–50mg/kg/day) may lead to reappearance of resistant strains.</li><li class="elsevierStyleListItem" id="lsti0010">–Children with respiratory infections frequently vomit, which may cause infradosage scenarios, especially if low doses are used.</li><li class="elsevierStyleListItem" id="lsti0015">–In pneumococcal infections of the upper airways (acute otitis media and sinusitis), it is necessary to continue to use high doses due to lower penetration of drugs in these locations. It is preferable to harmonise the dosage of this oral antibiotic for all pneumococcal infections, for the purpose of minimising prescription errors.</li></ul>The use of clavulanic acid together with amoxicillin in children with typical CAP with no underlying disease and vaccinated against H. influenzae type b, is not justified if there is suspicion of probable pneumococci aetiology, since S. pneumoniae drug-resistance through the production of β-lactamases is still unclear. Furthermore, their use is associated, relatively frequently, with gastrointestinal symptomatology, particularly diarrhoea, which can decrease absorption of amoxicillin.Macrolides should not be used for the treatment of typical CAP for many reasons, the most important being current resistance of S. pneumoniae to these antibiotics and the risk of bacteraemia in these patients.<a class="elsevierStyleCrossRef" href="#bib0275">17</a> Despite that, they are often incorrectly prescribed for CAP.<a class="elsevierStyleCrossRef" href="#bib0215">5</a>The recommended duration of treatment in a patient with typical CAP with no complications and not requiring admission is 7 days. There are several meta-analyses, based mainly on trials carried out in developing countries, which showed that 3 days of oral amoxicillin will be effective in treating children of 2–59 months of age with CAP that do not require hospitalisation. Although this strategy reduces costs,<a class="elsevierStyleCrossRefs" href="#bib0280">18,19</a> it is associated with a high rate of therapeutic failure, and therefore should not be used in Spain.Atypical CAPIn the case of atypical CAP in children under 4–5 years old, the aetiology is usually viral, and therefore no antibiotics are prescribed. In children over 4–5 years old, in whom M. pneumoniae aetiology is more frequent (up to 40% of CAP in this age group)<a class="elsevierStyleCrossRef" href="#bib0290">20</a> and, to a lesser extent, C. pneumoniae, the use of oral macrolides is recommended,<a class="elsevierStyleCrossRefs" href="#bib0265">15,20</a> although there is no clear evidence of its effectiveness in resolving CAP in this population.<a class="elsevierStyleCrossRefs" href="#bib0295">21,22</a>The macrolides most used currently (azithromycin and clarithromycin) and their recommended dosage are described in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>.<a class="elsevierStyleCrossRef" href="#bib0265">15</a> Erythromycin is clearly not used due to its adverse effects (mainly gastrointestinal) and complicated dosing regimen (every 6h, 10–14 days), which limits its effectiveness.Evolution and follow-upOnce CAP has been diagnosed and treatment has started a clinical assessment by the paediatrician is recommended after 48h. In non-complicated cases, 90% of patients are afebrile 48–72h after starting antibiotic treatment, and do not need further blood tests or radiological follow-up.<a class="elsevierStyleCrossRef" href="#bib0205">3</a>Only a small proportion need hospital admission. The management of therapeutic failure and the assessment of the hospital admission will be addressed in the second part of this document.Preventive measures. VaccinesVaccination against certain microorganisms has proven to have an impact on the incidence and mortality of CAP worldwide. The aetiological agents for which there are vaccines available are S. pneumoniae, H. influenzae type b and the flu virus.Vaccination against S. pneumoniaeThe release of the heptavalent conjugate vaccine led to a global reduction of invasive pneumococcal disease (IPD) in children, given its effect on nasopharyngeal colonisation by the serotypes included in the vaccine and, consequently, in its clinical forms.<a class="elsevierStyleCrossRef" href="#bib0305">23</a> However, incidence of IPD has increased in recent years, mainly complicated CAP especially in children over 2 years,<a class="elsevierStyleCrossRef" href="#bib0310">24</a> produced by serotypes not included in the vaccine.<a class="elsevierStyleCrossRef" href="#bib0305">23</a> In Spain, the most frequent are: 1, 19A, 7F, 3, 6A, 19F. Serotype 1 mainly affects children over 24 months of age and causes, in particular, bacterial pneumonia and pleural empyema. Serotypes 1, 19A and 3 caused 85% of pleural empyema of children in Spain, before the development of new vaccines, according to a study carried out by Laboratorio Español de Referencia de Neumococo del Instituto Carlos III.<a class="elsevierStyleCrossRef" href="#bib0315">25</a> Most serotypes noted are uniformly sensitive to penicillin, except serotype 19A, associated more frequently with resistance, including cephotaxime.Two conjugated antipneumococcal vaccines are currently authorised in children: decavalent vaccine (VNC10) (Synflorix®, GSK), up to 5 years of age, and tridecavalent (VNC13) (Prevenar 13®, Pfizer), authorised in children up to 17 years of age. Systematic antipneumococcal vaccination is still recommended by the Advisory Committee of Vaccines of the Spanish Paediatric Association in its annual immunisation report.<a class="elsevierStyleCrossRef" href="#bib0320">26</a>13-valent pneumococcal conjugate vaccinePCV13 has the 7 serotypes of the VNC7 and the following 6 additional serotypes: 1, 3, 5, 6A, 7F and 19A, and is approved for the prevention of CAP. Currently, PCV13 offers the widest coverage against pneumococcal disease worldwide,<a class="elsevierStyleCrossRef" href="#bib0305">23</a> including Spain,<a class="elsevierStyleCrossRefs" href="#bib0235">9,10,25</a> and therefore, it is recommended for all children under 5 years of age, both healthy and at risk for disease.<a class="elsevierStyleCrossRef" href="#bib0325">27</a>In Madrid, as of July 2012, PCV13 is no longer subsidised, and therefore coverage has decreased to approximately 70%. Still, the data are very good so far, with a decrease in bacterial CAP (87%), pleural pneumococcal empyema (61%) and meningitis (72%), compared with 2007–2010.<a class="elsevierStyleCrossRef" href="#bib0235">9</a>In the United Kingdom, one year after starting vaccination, PCV13 was shown to be effective against additional serotypes (1, 3, 5, 6A, 7F and 19A) in over 50% in children under 2 years of age.<a class="elsevierStyleCrossRef" href="#bib0330">28</a>In France, where there has been systematic vaccination with PCV13 since 2010 (previously with PCV7) recent studies in children under 15 years of age have shown a 16% decrease in CAP overall, and 63% decrease in pneumococcal CAP. This is in addition to a 53% decrease in cases with pleural effusion.<a class="elsevierStyleCrossRef" href="#bib0335">29</a>In the USA, with systematic vaccination with PCV13 since 2010 (previously with PCV7) a 50% overall reduction In IPD has been reported, and a 70% reduction in cases attributed to PCV13, while hospitalisation for CAP in children under 2 years of age fell by 65% in 2012.<a class="elsevierStyleCrossRefs" href="#bib0340">30,27</a>In Latin America, several countries have published good results after the introduction of PCV13 in their vaccination calendars, including Argentina, with a 41% reduction in cases of CAP in children under 5 years old.<a class="elsevierStyleCrossRef" href="#bib0345">31</a> In Uruguay, hospitalisation for CAP in the under-14 age group has decreased by 78% overall, and by 92% in cases of pneumococcal origin.<a class="elsevierStyleCrossRef" href="#bib0350">32</a>10-valent pneumococcal conjugated vaccinePCV10 in addition to the serotypes contained in PCV7 incorporates another 3 serotypes: 1, 5 and 7F, and is approved for the prevention of CAP. In a randomised clinical trial (COMPAS study), carried out in approximately 24,000 infants in 3 Latin American countries, a 22% efficacy over typical CAP was reported (95% CI, 7.7–34.2).<a class="elsevierStyleCrossRef" href="#bib0355">33</a>In Brazil, a country with low incidence of serotype 19A since the introduction of systematic vaccination with PCV10 there has been a 15% decrease in mortality from pneumonia in children under 24 months.<a class="elsevierStyleCrossRef" href="#bib0360">34</a>23-valent pneumococcal polysaccharide vaccineThe 23-valent pneumococcal polysaccharide vaccine is still recommended in children over 2 years of age at risk for infection, although it probably has little impact on the prevention of CAP.Vaccination against H. influenzae type bSince the introduction of the vaccine against Hib in the late 90s, there has been a drastic decrease of CAP caused by this microorganism. In some reports, a reduction of up to 30% of NACs has radiologically confirmed.<a class="elsevierStyleCrossRefs" href="#bib0365">35,36</a>Since non-typifiable H. influenzae is a very infrequent cause of CAP in previously healthy children, the PCV10 vaccine (due to its non-typifiable Hi component) probably has little impact.Flu vaccineThe flu virus is a cause per se of CAP in the epidemic season. Also, in the cases of bacterial CAP co-infection with this virus is associated with a higher incidence of complicated forms,<a class="elsevierStyleCrossRef" href="#bib0375">37</a> especially in cases where S. aureus is isolated, or no micro-organism is isolated.According to current guidelines, the flu vaccine is recommended, for patients over 6 months of age with risk factors of complications, or for those living in the same household.<a class="elsevierStyleCrossRef" href="#bib0380">38</a> Currently, the trivalent inactivated vaccine, which can be administered intramuscularly, is usually used in children. Some countries, such as the USA and the United Kingdom, have introduced the intranasal live attenuated influenza vaccine for children over 2 years of age with no history of bronchialhyperresponsiveness or asthma. This formulation will probably be available in Spain in the 2015–2016 vaccination campaign.FundingThe authors declare they have not received any type of funding for this study.Conflict of interestsConflict of interests of the authors as regards the document (in the last 5 years):<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">–DMP has collaborated in teaching activities funded by GlaxoSmithKline, Pfizer and Sanofi Pasteur MSD, as a researcher in a clinical study conducted by Novartis and as a consultant on the Advisory Board of Astra-Zeneca and Pfizer.</li><li class="elsevierStyleListItem" id="lsti0025">–AAM presents no conflict of interests.</li><li class="elsevierStyleListItem" id="lsti0030">–ATG has collaborated in research activities funded by Pfizer.</li><li class="elsevierStyleListItem" id="lsti0035">–AEM has collaborated in teaching activities funded by Novartis, as a researcher in a multicentre study sponsored by GlaxoSmithKline and as a consultant in an Advisory Board of Gilead.</li><li class="elsevierStyleListItem" id="lsti0040">–JFM has collaborated in teaching activities funded by Gilead and Abbvie.</li><li class="elsevierStyleListItem" id="lsti0045">–JGG has collaborated in teaching activities funded by Pfizer and Sanofi Pasteur MSD.</li><li class="elsevierStyleListItem" id="lsti0050">–AMG has participated as a consultant in the Advisory Board of Abbvie and Gilead, has received institutional investigation grants from Abbvie and grants to attend congresses organised by Abbvie, Actelion, Ferrer, GlaxoSmithKline and Novartis.</li><li class="elsevierStyleListItem" id="lsti0055">–CRGL has collaborated in teaching activities funded by GlaxoSmithKline, Novartis, Pfizer and Sanofi Pasteur MSD, as a researcher in clinical trials conducted by GlaxoSmithKline and as a consultant on the Advisory Board of Astra-Zeneca, Novartis, GlaxoSmithKline and Pfizer.</li><li class="elsevierStyleListItem" id="lsti0060">–JRC has collaborated in teaching activities funded by GlaxoSmithKline, Pfizer and Sanofi Pasteur MSD and as a researcher in clinical trials conducted by GlaxoSmithKline and Pfizer.</li><li class="elsevierStyleListItem" id="lsti0065">–JSL has collaborated as a researcher in clinical trials conducted by GlaxoSmithKline and Roche.</li></ul>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres597293" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec612014" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres597292" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec612013" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Current status of resistances to antimicrobial drugs" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Adjuvant support treatment" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ambulatory treatment of non-complicated CAP with antibiotics" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Indication for the use of antibiotics" ] 1 => array:3 [ "identificador" => "sec0030" "titulo" => "Selection of the antibiotic, route, dosage and duration" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Typical CAP" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Atypical CAP" ] ] ] ] ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Evolution and follow-up" ] 9 => array:3 [ "identificador" => "sec0050" "titulo" => "Preventive measures. Vaccines" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0055" "titulo" => "Vaccination against S. pneumoniae" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "13-valent pneumococcal conjugate vaccine" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "10-valent pneumococcal conjugated vaccine" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "23-valent pneumococcal polysaccharide vaccine" ] ] ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Vaccination against H. influenzae type b" ] ] ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Flu vaccine" ] 11 => array:2 [ "identificador" => "sec0085" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflict of interests" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-01" "fechaAceptado" => "2014-10-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec612014" "palabras" => array:7 [ 0 => "Community acquired pneumonia" 1 => "Children" 2 => "Treatment" 3 => "Prevention" 4 => "Streptococcus pneumoniae" 5 => "Resistances" 6 => "Vaccines" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec612013" "palabras" => array:7 [ 0 => "Neumonía adquirida en la comunidad" 1 => "Niños" 2 => "Tratamiento" 3 => "Prevención" 4 => "Streptococcus pneumoniae" 5 => "Resistencias" 6 => "Vacunas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "There have been significant changes in community acquired pneumonia (CAP) in children in the last decade. These changes are related to epidemiology and clinical presentation. Resistance to antibiotics is also a changing issue. These all have to be considered when treating Community acquired pneumonia (CAP). In this document, two of the main Spanish pediatric societies involved in the treatment of CAP in children, propose a consensus concerning therapeutic approach. These societies are the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases. The Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP) has also been involved in the prevention of CAP. An attempt is made to provide up-to-date guidelines to all paediatricians. The first part of the statement presents the approach to ambulatory, previously healthy children. We also review the prevention with currently available vaccines. In a second part, special situations and complicated forms will be addressed." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La neumonía adquirida en la comunidad (NAC) en la edad pediátrica ha sufrido, en la última década, una serie de cambios epidemiológicos, clínicos, etiológicos y de resistencias a antibióticos, que obligan a replantear su abordaje terapéutico. En este documento, dos de las principales sociedades de especialidades pediátricas involucradas en el diagnóstico y tratamiento de esta entidad, como son la Sociedad Española de Infectología Pediátrica y la Sociedad Española de Neumología Pediátrica, así como el Comité Asesor de Vacunas de la AEP, proponen unas pautas consensuadas de tratamiento y prevención, con el fin de proporcionar a todos los pediatras una guía actualizada. En esta primera parte del consenso, se aborda el tratamiento de los pacientes sin enfermedades de base relevantes con NAC que no precisan ingreso hospitalario, así como la prevención global de esta patología con vacunas. En un siguiente documento se expondrá el abordaje terapéutico tanto de aquellos pacientes en situaciones especiales como de las formas complicadas de la enfermedad." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Moreno-Pérez D, Martín AA, García AT, Montaner AE, Mulet JF, García JJG, et al. Neumonía adquirida en la comunidad: tratamiento ambulatorio y prevención. An Pediatr (Barc). 2015;83:439.e1–439.e7." ] 1 => array:3 [ "etiqueta" => "1" "nota" => "Los nombres de los componentes de las Sociedades están relacionados en el anexo." "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "apendice" => "The affiliation of the authors is as follows:<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>" "etiqueta" => "Appendix" "identificador" => "sec0095" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Adapted from Pérez-Trallero et al.<a class="elsevierStyleCrossRef" href="#bib0230">8</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteria \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of antibiotics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage pf sensitive strains \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Streptococcus pneumoniae, in infections outside the central nervous system \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">β-Lactams \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicillin (at high doses): 98.8% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ampicillin: 93.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Parenteral penicillin: 99.8% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cephotaxime: 99.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral cefuroxime: 94.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Parenteral cefuroxime: 99.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Macrolides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Erythromycin, clarithromycin, azithromycin: 75–79% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quinolones \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Levofloxacin: 97.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Haemophilus influenzae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">β-Lactams \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicillin, ampicillin, penicillin: 85% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Macrolides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Streptococcus pyogenes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">β-lactams \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Macrolides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Erythromycin, clarithromycin, azithromycin: 65% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab976905.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Sensitivity of the main bacteria causing CAP in Spain (data from the SAUCE-4 study)." ] ] 1 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Typical CAP (with suspected or confirmed aetiology)</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Name \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Posology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Current duration \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Oral amoxicillin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80–90mg/kg/day, divided into 3 doses (every 8h)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 days \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab976904.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Atypical CAP with confirmed aetiology or high suspicion of Mycoplasma or Chlamydia. Most used macrolides</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Name \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Posology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Oral azithromycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10mg/kg every 24h (maximum: 500mg/day)<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Oral clarithromycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15mg/kg/day, every 12h (maximum dose: 1g/day) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 days \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab976903.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The maximum recommended dose for children is 2g every 8h (6g/day), according to the data sheet." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "In the USA the same total dose is used, but distributed along a period of 5 days (first day 10mg/kg; 5mg/kg/24h from days 2–5), because it is the posology approved by the FDA, but provides no advantage over the 3 days approved by the European Medication Agency (EMA)." ] ] ] "descripcion" => array:1 [ "en" => "Ambulatory antibiotic treatment for children with CAP who do not need hospitalisation." ] ] 2 => array:5 [ "identificador" => "tbl0005" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Respiratory Infections Work Group. Spanish Society for Paediatric Infectious Diseases (SEIP in Spanish): \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">D Moreno-Pérez, J.J. García García, C Rodrigo Gonzalo de Lliria, J Ruiz Contreras and J Saavedra Lozano \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Spanish Society of Paediatric Pneumology (SENP in Spanish): \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">A Andrés Martín, A Escribano Montaner, J Figuerola Mulet, A Moreno-Galdó \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Advisory Committee of the Paediatric Spanish Association (CAV-AEP in Spanish): \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">D Moreno-Pérez, J Ruiz Contreras \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab976902.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "for the Severe Acute Lower Respiratory Infections Working Group. 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Spanish Association of Paediatrics

Community acquired pneumonia in children: Outpatient treatment and prevention

Neumonía adquirida en la comunidad: tratamiento ambulatorio y prevención

D. Moreno-Péreza,

Corresponding author

dmp.malaga@gmail.com

Corresponding author.

, A. Andrés Martínb, A. Tagarro Garcíac, A. Escribano Montanerd, J. Figuerola Mulete, J.J. García Garcíaf, A. Moreno-Galdóg, C. Rodrigo Gonzalo de Liriah, J. Ruiz Contrerasi, J. Saavedra Lozanoj, representing the Sociedad Española de Infectología Pediátrica (SEIP), Sociedad Española de Neumología Pediátrica (SENP) and the Comité Asesor de Vacunas de la Asociación Española de Pediatría (CAV-AEP) 1

a Infectología Pediátrica e Inmunodeficiencias, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Grupo de Investigación IBIMA, Departamento de Pediatría y Farmacología, Facultad de Medicina, Universidad de Málaga, Málaga, Spain

b Sección de Neumología Pediátrica, Servicio de Pediatría, Hospital Universitario Virgen Macarena, Departamento de Farmacología, Pediatría y Radiología, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain

c Servicio de Pediatría, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain

d Unidad de Neumología Pediátrica y Fibrosis Quística, Servicio de Pediatría, Hospital Clínico Universitario, Universitat de València, Valencia, Spain

e Unidad de Neumología y Alergia Pediátrica, Servicio de Pediatría, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, Spain

f Servicio de Pediatría, Hospital San Joan de Dèu, Universitat de Barcelona, Barcelona, Spain

g Sección de Neumología Pediátrica y Fibrosis Quística, Hospital Universitario Vall d¿Hebron, Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain

h Unidad de Enfermedades Infecciosas e Inmunología Clínica, Servicio de Pediatría, Hospital Universitario Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain

i Servicio de Pediatría, Hospital 12 de Octubre, Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain

j Unidad de Infectología Pediátrica, Servicio de Pediatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain

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pneumoniae</span>&#46; Viruses affect mainly children under 4&#8211;5 years of age&#44; while <span class="elsevierStyleItalic">S&#46; pneumoniae</span> affects children of any age&#46; However&#44; in the last 10&#8211;15 years the incidence of complicated pneumonias&#44; manifesting as either pleural effusion or necrotising pneumonia&#44; has steadily increased&#46; Changes have also been observed in the age of onset of complicated pneumonias&#46; Where previously it was more frequent in children under the age of 2&#8211;3 years&#44; it now predominates in children 2&#8211;5 years of age&#46; There has also been a slight increase in the number of cases caused by <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;<span class="elsevierStyleItalic">S&#46; aureus</span>&#41;&#44; some caused by strains produced by certain virus factors which make them more serious&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Paediatricians treating children with CAP<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> have access to a huge range of therapies&#44; and in many countries clinical guidelines are not followed&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;6</span></a> Therefore&#44; one of the most ambitious goals of this consensus is to harmonise therapeutic measures against this disease in Spain and improve control measures&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> In this document&#44; based on the scientific information available and the experience of the authors&#44; initial measures are proposed which we believe are more adequate for the therapeutic treatment of CAP&#46; Also&#44; the prevention measures available against CAP in the population of children are summarised&#46; In another document&#44; soon to be published in this journal the therapeutic approach to complicated cases and special circumstances will be presented&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Current status of resistances to antimicrobial drugs</span><p id="par0030" class="elsevierStylePara elsevierViewall">Drug-resistant bacteria that can potentially cause CAP include <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; <span class="elsevierStyleItalic">Streptococcus pyogenes</span> &#40;<span class="elsevierStyleItalic">S&#46; pyogenes</span>&#41; and <span class="elsevierStyleItalic">H&#46; influenzae</span> type b&#46; In Spain&#44; other causal agents of CAP&#44; such as <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> &#40;<span class="elsevierStyleItalic">M&#46; pneumoniae</span>&#41; or <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span> &#40;<span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#41;&#44; or viruses&#44; are not drug-resistant&#46; <span class="elsevierStyleItalic">M&#46; pneumoniae</span> and <span class="elsevierStyleItalic">C&#46; pneumoniae</span> are usually sensitive to macrolides and the only virus to be treated with antiviral drugs&#44; the flu virus&#44; so far does not present resistance to oseltamivir in our area&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The most reliable data on the drug-resistance of the main respiratory pathogens in our area are periodically provided by the multi-centre study known as Sensitivity to Antibiotic Drugs Used in the Community in Spain &#40;SAUCE in Spanish&#41;&#46; The latest&#44; published in 2010 as the SAUCE-4 study&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> offers results on sensitivity and resistance according to official cutoff points &#40;<span class="elsevierStyleItalic">CLSI cutoff points</span>&#41;&#46; It contains a total of 2559 isolations of <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; 2287 of <span class="elsevierStyleItalic">S&#46; pyogenes</span> and 2287 of <span class="elsevierStyleItalic">H&#46; influenzae</span>&#44; and these are compared to those recorded in the previous 11 years&#46; In summary&#44; the most relevant data are described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#46; For <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; as regards sensitivity to &#946;-lactams&#44; currently almost all strains circulating in Spain are sensitive to oral amoxicillin and intravenous penicillin and ampicillin&#44; and also cefuroxime&#44; if we wish to broaden the spectrum&#46; They are all sensitive to cephotaxime&#46; In recent years&#44; the percentage of penicillin-resistant strains &#40;intermediate sensitivity or total resistance&#41; have risen from 60&#46;0&#37; to 22&#46;9&#37;&#46; The proportion of strains with total resistance to oral penicillin &#40;MIC<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2&#41; has decreased drastically from 36&#46;5&#37; to 0&#46;9&#37;&#46; Also&#44; 0&#37; presents total resistance &#40;MIC<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>8&#41; for parenteral penicillin and only 0&#46;2&#37; intermediate sensitivity &#40;MIC<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46; There are still high rates of resistance to macrolides &#40;21&#8211;25&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">For <span class="elsevierStyleItalic">H&#46; influenzae</span>&#44; 15&#46;7&#37; are producers of &#946;-lactamases and&#44; therefore&#44; resistant to penicillin&#44; ampicillin or amoxicillin&#46; This percentage has decreased&#44; from the previous level of 25&#46;7&#37;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">These data&#44; based on samples from children and adults taken 6&#8211;7 years ago&#44; can be combined with the findings of a recent study by Heracles in the Community of Madrid &#40;May 2011&#8211;April 2013&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10</span></a> where 100&#37; of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> strains isolated in children under 15 years old with invasive pneumococci disease outside the central nervous system&#8212;including bacteraemia pneumonias and empyema&#8212;are sensitive to penicillin and cephotaxime&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Adjuvant support treatment</span><p id="par0050" class="elsevierStylePara elsevierViewall">In children with CAP&#44; antibiotic therapy at times needs to be complemented with other strategies&#44; although this is less frequent in patients not requiring hospitalisation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Children with pneumonia usually feel associated pain &#40;pleuritic&#44; abdominal&#44; headache&#41; and discomfort or pain due to inflammation of upper airways &#40;otalgia&#44; odynophagia&#41;&#46; Analgesia is recommended for relief&#44; especially in cases of pleuritic pain&#44; because it interferes with coughing and breathing&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#44;12</span></a> Paracetamol can be used &#40;15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;6<span class="elsevierStyleHsp" style=""></span>h&#59; up to a maximum of 75<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; or ibuprofen &#40;5&#8211;10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;6&#8211;8<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Fever must be controlled with these same agents&#44; as oxygen requirements increase&#46; There is insufficient evidence that mucolytic and cough suppressants are beneficial&#44; and in theory&#44; medications with codeine or antihistamines should not be used in young children&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Increased effort of breathing and fever increase the requirement for fluids&#46; The ideal way to provide them is orally&#44; in small amounts and frequently&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ambulatory treatment of non-complicated CAP with antibiotics</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Indication for the use of antibiotics</span><p id="par0065" class="elsevierStylePara elsevierViewall">Empirical treatment of CAP is based on the pathogens most frequently involved&#46; However&#44; one of the most important problems is correct distinction between probable viral aetiology and probable bacterial aetiology&#46; Clinicians tend&#44; mistakenly&#44; to use antibiotics in excess&#44; which leads to an increase in antimicrobial resistances&#46; In patients aged less than 2 years&#44; with mild clinical lower airway manifestations and a history of correct immunisation according to age against <span class="elsevierStyleItalic">H&#46; influenzae</span> type b and <span class="elsevierStyleItalic">S&#46; pneumoniae</span> bacterial aetiology is unlikely&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Antibiotics are indicated in typical CAP where bacterial aetiology is suspected&#46; In cases of atypical CAP they should only be used in children over 4&#8211;5 years old and in certain younger patients if the infection is serious&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">For treatment under special circumstances &#40;allergy to &#946;-lactams&#44; base disease&#44; immunodepressed&#44; etc&#46;&#41;&#44; or patients requiring hospitalisation&#44; more information will be available in the specific document that will be published in a subsequent issue of this journal&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Selection of the antibiotic&#44; route&#44; dosage and duration</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Typical CAP</span><p id="par0080" class="elsevierStylePara elsevierViewall">If it has been decided to initiate ambulatory antibiotic treatment in typical CAP with no criteria for hospital admission&#44; considering that most are caused by pneumococci and that&#44; currently&#44; almost all are sensitive to penicillin and amoxicillin&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> the antibiotic of choice is 80&#8211;90<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day oral amoxicillin&#44; every 8<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46; This recommendation is consistent with current international guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;15</span></a> The maximum recommended dose&#44; according to the package leaflet&#44; is 2<span class="elsevierStyleHsp" style=""></span>g every 8<span class="elsevierStyleHsp" style=""></span>h&#44; given the good tolerance of this antibiotic&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">There may be some controversy regarding the recommended dose&#46; Given the good absorption of this drug and its good penetration at a pulmonary level&#44; as well as the low rates of resistances of <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; doses of 40&#8211;50<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day will suffice in most cases&#46; This consensus recommends&#44; however&#44; higher doses &#40;80&#8211;90<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; due to the following reasons&#58;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0090" class="elsevierStylePara elsevierViewall">The use of low doses &#40;40&#8211;50<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; may lead to reappearance of resistant strains&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Children with respiratory infections frequently vomit&#44; which may cause infradosage scenarios&#44; especially if low doses are used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">In pneumococcal infections of the upper airways &#40;acute otitis media and sinusitis&#41;&#44; it is necessary to continue to use high doses due to lower penetration of drugs in these locations&#46; It is preferable to harmonise the dosage of this oral antibiotic for all pneumococcal infections&#44; for the purpose of minimising prescription errors&#46;</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">The use of clavulanic acid together with amoxicillin in children with typical CAP with no underlying disease and vaccinated against <span class="elsevierStyleItalic">H&#46; influenzae</span> type b&#44; is not justified if there is suspicion of probable pneumococci aetiology&#44; since <span class="elsevierStyleItalic">S&#46; pneumoniae</span> drug-resistance through the production of &#946;-lactamases is still unclear&#46; Furthermore&#44; their use is associated&#44; relatively frequently&#44; with gastrointestinal symptomatology&#44; particularly diarrhoea&#44; which can decrease absorption of amoxicillin&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Macrolides should not be used for the treatment of typical CAP for many reasons&#44; the most important being current resistance of <span class="elsevierStyleItalic">S&#46; pneumoniae</span> to these antibiotics and the risk of bacteraemia in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> Despite that&#44; they are often incorrectly prescribed for CAP&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The recommended duration of treatment in a patient with typical CAP with no complications and not requiring admission is 7 days&#46; There are several meta-analyses&#44; based mainly on trials carried out in developing countries&#44; which showed that 3 days of oral amoxicillin will be effective in treating children of 2&#8211;59 months of age with CAP that do not require hospitalisation&#46; Although this strategy reduces costs&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">18&#44;19</span></a> it is associated with a high rate of therapeutic failure&#44; and therefore should not be used in Spain&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Atypical CAP</span><p id="par0120" class="elsevierStylePara elsevierViewall">In the case of atypical CAP in children under 4&#8211;5 years old&#44; the aetiology is usually viral&#44; and therefore no antibiotics are prescribed&#46; In children over 4&#8211;5 years old&#44; in whom <span class="elsevierStyleItalic">M&#46; pneumoniae</span> aetiology is more frequent &#40;up to 40&#37; of CAP in this age group&#41;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> and&#44; to a lesser extent&#44; <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#44; the use of oral macrolides is recommended&#44;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">15&#44;20</span></a> although there is no clear evidence of its effectiveness in resolving CAP in this population&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The macrolides most used currently &#40;azithromycin and clarithromycin&#41; and their recommended dosage are described in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> Erythromycin is clearly not used due to its adverse effects &#40;mainly gastrointestinal&#41; and complicated dosing regimen &#40;every 6<span class="elsevierStyleHsp" style=""></span>h&#44; 10&#8211;14 days&#41;&#44; which limits its effectiveness&#46;</p></span></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Evolution and follow-up</span><p id="par0130" class="elsevierStylePara elsevierViewall">Once CAP has been diagnosed and treatment has started a clinical assessment by the paediatrician is recommended after 48<span class="elsevierStyleHsp" style=""></span>h&#46; In non-complicated cases&#44; 90&#37; of patients are afebrile 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h after starting antibiotic treatment&#44; and do not need further blood tests or radiological follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Only a small proportion need hospital admission&#46; The management of therapeutic failure and the assessment of the hospital admission will be addressed in the second part of this document&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Preventive measures&#46; Vaccines</span><p id="par0140" class="elsevierStylePara elsevierViewall">Vaccination against certain microorganisms has proven to have an impact on the incidence and mortality of CAP worldwide&#46; The aetiological agents for which there are vaccines available are <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; <span class="elsevierStyleItalic">H&#46; influenzae</span> type b and the flu virus&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Vaccination against <span class="elsevierStyleItalic">S&#46; pneumoniae</span></span><p id="par0145" class="elsevierStylePara elsevierViewall">The release of the heptavalent conjugate vaccine led to a global reduction of invasive pneumococcal disease &#40;IPD&#41; in children&#44; given its effect on nasopharyngeal colonisation by the serotypes included in the vaccine and&#44; consequently&#44; in its clinical forms&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> However&#44; incidence of IPD has increased in recent years&#44; mainly complicated CAP especially in children over 2 years&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> produced by serotypes not included in the vaccine&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> In Spain&#44; the most frequent are&#58; 1&#44; 19A&#44; 7F&#44; 3&#44; 6A&#44; 19F&#46; Serotype 1 mainly affects children over 24 months of age and causes&#44; in particular&#44; bacterial pneumonia and pleural empyema&#46; Serotypes 1&#44; 19A and 3 caused 85&#37; of pleural empyema of children in Spain&#44; before the development of new vaccines&#44; according to a study carried out by Laboratorio Espa&#241;ol de Referencia de Neumococo del Instituto Carlos III&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> Most serotypes noted are uniformly sensitive to penicillin&#44; except serotype 19A&#44; associated more frequently with resistance&#44; including cephotaxime&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Two conjugated antipneumococcal vaccines are currently authorised in children&#58; decavalent vaccine &#40;VNC10&#41; &#40;Synflorix<span class="elsevierStyleSup">&#174;</span>&#44; GSK&#41;&#44; up to 5 years of age&#44; and tridecavalent &#40;VNC13&#41; &#40;Prevenar 13<span class="elsevierStyleSup">&#174;</span>&#44; Pfizer&#41;&#44; authorised in children up to 17 years of age&#46; Systematic antipneumococcal vaccination is still recommended by the Advisory Committee of Vaccines of the Spanish Paediatric Association in its annual immunisation report&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a></p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">13-valent pneumococcal conjugate vaccine</span><p id="par0155" class="elsevierStylePara elsevierViewall">PCV13 has the 7 serotypes of the VNC7 and the following 6 additional serotypes&#58; 1&#44; 3&#44; 5&#44; 6A&#44; 7F and 19A&#44; and is approved for the prevention of CAP&#46; Currently&#44; PCV13 offers the widest coverage against pneumococcal disease worldwide&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> including Spain&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10&#44;25</span></a> and therefore&#44; it is recommended for all children under 5 years of age&#44; both healthy and at risk for disease&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In Madrid&#44; as of July 2012&#44; PCV13 is no longer subsidised&#44; and therefore coverage has decreased to approximately 70&#37;&#46; Still&#44; the data are very good so far&#44; with a decrease in bacterial CAP &#40;87&#37;&#41;&#44; pleural pneumococcal empyema &#40;61&#37;&#41; and meningitis &#40;72&#37;&#41;&#44; compared with 2007&#8211;2010&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In the United Kingdom&#44; one year after starting vaccination&#44; PCV13 was shown to be effective against additional serotypes &#40;1&#44; 3&#44; 5&#44; 6A&#44; 7F and 19A&#41; in over 50&#37; in children under 2 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In France&#44; where there has been systematic vaccination with PCV13 since 2010 &#40;previously with PCV7&#41; recent studies in children under 15 years of age have shown a 16&#37; decrease in CAP overall&#44; and 63&#37; decrease in pneumococcal CAP&#46; This is in addition to a 53&#37; decrease in cases with pleural effusion&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In the USA&#44; with systematic vaccination with PCV13 since 2010 &#40;previously with PCV7&#41; a 50&#37; overall reduction In IPD has been reported&#44; and a 70&#37; reduction in cases attributed to PCV13&#44; while hospitalisation for CAP in children under 2 years of age fell by 65&#37; in 2012&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">30&#44;27</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In Latin America&#44; several countries have published good results after the introduction of PCV13 in their vaccination calendars&#44; including Argentina&#44; with a 41&#37; reduction in cases of CAP in children under 5 years old&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> In Uruguay&#44; hospitalisation for CAP in the under-14 age group has decreased by 78&#37; overall&#44; and by 92&#37; in cases of pneumococcal origin&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">10-valent pneumococcal conjugated vaccine</span><p id="par0185" class="elsevierStylePara elsevierViewall">PCV10 in addition to the serotypes contained in PCV7 incorporates another 3 serotypes&#58; 1&#44; 5 and 7F&#44; and is approved for the prevention of CAP&#46; In a randomised clinical trial &#40;COMPAS study&#41;&#44; carried out in approximately 24&#44;000 infants in 3 Latin American countries&#44; a 22&#37; efficacy over typical CAP was reported &#40;95&#37; CI&#44; 7&#46;7&#8211;34&#46;2&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In Brazil&#44; a country with low incidence of serotype 19A since the introduction of systematic vaccination with PCV10 there has been a 15&#37; decrease in mortality from pneumonia in children under 24 months&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">23-valent pneumococcal polysaccharide vaccine</span><p id="par0290" class="elsevierStylePara elsevierViewall">The 23-valent pneumococcal polysaccharide vaccine is still recommended in children over 2 years of age at risk for infection&#44; although it probably has little impact on the prevention of CAP&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Vaccination against <span class="elsevierStyleItalic">H&#46; influenzae</span> type b</span><p id="par0200" class="elsevierStylePara elsevierViewall">Since the introduction of the vaccine against Hib in the late 90s&#44; there has been a drastic decrease of CAP caused by this microorganism&#46; In some reports&#44; a reduction of up to 30&#37; of NACs has radiologically confirmed&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">35&#44;36</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Since non-typifiable <span class="elsevierStyleItalic">H&#46; influenzae</span> is a very infrequent cause of CAP in previously healthy children&#44; the PCV10 vaccine &#40;due to its non-typifiable Hi component&#41; probably has little impact&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Flu vaccine</span><p id="par0210" class="elsevierStylePara elsevierViewall">The flu virus is a cause <span class="elsevierStyleItalic">per se</span> of CAP in the epidemic season&#46; Also&#44; in the cases of bacterial CAP co-infection with this virus is associated with a higher incidence of complicated forms&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> especially in cases where <span class="elsevierStyleItalic">S&#46; aureus</span> is isolated&#44; or no micro-organism is isolated&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">According to current guidelines&#44; the flu vaccine is recommended&#44; for patients over 6 months of age with risk factors of complications&#44; or for those living in the same household&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> Currently&#44; the trivalent inactivated vaccine&#44; which can be administered intramuscularly&#44; is usually used in children&#46; Some countries&#44; such as the USA and the United Kingdom&#44; have introduced the intranasal live attenuated influenza vaccine for children over 2 years of age with no history of bronchialhyperresponsiveness or asthma&#46; This formulation will probably be available in Spain in the 2015&#8211;2016 vaccination campaign&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare they have not received any type of funding for this study&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0225" class="elsevierStylePara elsevierViewall">Conflict of interests of the authors as regards the document &#40;in the last 5 years&#41;&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0230" class="elsevierStylePara elsevierViewall">DMP has collaborated in teaching activities funded by GlaxoSmithKline&#44; Pfizer and Sanofi Pasteur MSD&#44; as a researcher in a clinical study conducted by Novartis and as a consultant on the Advisory Board of Astra-Zeneca and Pfizer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0235" class="elsevierStylePara elsevierViewall">AAM presents no conflict of interests&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0240" class="elsevierStylePara elsevierViewall">ATG has collaborated in research activities funded by Pfizer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0245" class="elsevierStylePara elsevierViewall">AEM has collaborated in teaching activities funded by Novartis&#44; as a researcher in a multicentre study sponsored by GlaxoSmithKline and as a consultant in an Advisory Board of Gilead&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0250" class="elsevierStylePara elsevierViewall">JFM has collaborated in teaching activities funded by Gilead and Abbvie&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8211;</span><p id="par0255" class="elsevierStylePara elsevierViewall">JGG has collaborated in teaching activities funded by Pfizer and Sanofi Pasteur MSD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8211;</span><p id="par0260" class="elsevierStylePara elsevierViewall">AMG has participated as a consultant in the Advisory Board of Abbvie and Gilead&#44; has received institutional investigation grants from Abbvie and grants to attend congresses organised by Abbvie&#44; Actelion&#44; Ferrer&#44; GlaxoSmithKline and Novartis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8211;</span><p id="par0265" class="elsevierStylePara elsevierViewall">CRGL has collaborated in teaching activities funded by GlaxoSmithKline&#44; Novartis&#44; Pfizer and Sanofi Pasteur MSD&#44; as a researcher in clinical trials conducted by GlaxoSmithKline and as a consultant on the Advisory Board of Astra-Zeneca&#44; Novartis&#44; GlaxoSmithKline and Pfizer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8211;</span><p id="par0270" class="elsevierStylePara elsevierViewall">JRC has collaborated in teaching activities funded by GlaxoSmithKline&#44; Pfizer and Sanofi Pasteur MSD and as a researcher in clinical trials conducted by GlaxoSmithKline and Pfizer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8211;</span><p id="par0275" class="elsevierStylePara elsevierViewall">JSL has collaborated as a researcher in clinical trials conducted by GlaxoSmithKline and Roche&#46;</p></li></ul></p></span></span>"
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              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec612014"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Current status of resistances to antimicrobial drugs"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Adjuvant support treatment"
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        7 => array:3 [
          "identificador" => "sec0020"
          "titulo" => "Ambulatory treatment of non-complicated CAP with antibiotics"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Indication for the use of antibiotics"
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            1 => array:3 [
              "identificador" => "sec0030"
              "titulo" => "Selection of the antibiotic&#44; route&#44; dosage and duration"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0035"
                  "titulo" => "Typical CAP"
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                  "identificador" => "sec0040"
                  "titulo" => "Atypical CAP"
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              ]
            ]
          ]
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        8 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Evolution and follow-up"
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        9 => array:3 [
          "identificador" => "sec0050"
          "titulo" => "Preventive measures&#46; Vaccines"
          "secciones" => array:2 [
            0 => array:3 [
              "identificador" => "sec0055"
              "titulo" => "Vaccination against S&#46; pneumoniae"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "13-valent pneumococcal conjugate vaccine"
                ]
                1 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "10-valent pneumococcal conjugated vaccine"
                ]
                2 => array:2 [
                  "identificador" => "sec0070"
                  "titulo" => "23-valent pneumococcal polysaccharide vaccine"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Vaccination against H&#46; influenzae type b"
            ]
          ]
        ]
        10 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Flu vaccine"
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        11 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Funding"
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        12 => array:2 [
          "identificador" => "sec0090"
          "titulo" => "Conflict of interests"
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        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
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    "fechaRecibido" => "2014-10-01"
    "fechaAceptado" => "2014-10-29"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec612014"
          "palabras" => array:7 [
            0 => "Community acquired pneumonia"
            1 => "Children"
            2 => "Treatment"
            3 => "Prevention"
            4 => "<span class="elsevierStyleItalic">Streptococcus pneumoniae</span>"
            5 => "Resistances"
            6 => "Vaccines"
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          "identificador" => "xpalclavsec612013"
          "palabras" => array:7 [
            0 => "Neumon&#237;a adquirida en la comunidad"
            1 => "Ni&#241;os"
            2 => "Tratamiento"
            3 => "Prevenci&#243;n"
            4 => "<span class="elsevierStyleItalic">Streptococcus pneumoniae</span>"
            5 => "Resistencias"
            6 => "Vacunas"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There have been significant changes in community acquired pneumonia &#40;CAP&#41; in children in the last decade&#46; These changes are related to epidemiology and clinical presentation&#46; Resistance to antibiotics is also a changing issue&#46; These all have to be considered when treating Community acquired pneumonia &#40;CAP&#41;&#46; In this document&#44; two of the main Spanish pediatric societies involved in the treatment of CAP in children&#44; propose a consensus concerning therapeutic approach&#46; These societies are the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases&#46; The Advisory Committee on Vaccines of the Spanish Association of Paediatrics &#40;CAV-AEP&#41; has also been involved in the prevention of CAP&#46; An attempt is made to provide up-to-date guidelines to all paediatricians&#46; The first part of the statement presents the approach to ambulatory&#44; previously healthy children&#46; We also review the prevention with currently available vaccines&#46; In a second part&#44; special situations and complicated forms will be addressed&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La neumon&#237;a adquirida en la comunidad &#40;NAC&#41; en la edad pedi&#225;trica ha sufrido&#44; en la &#250;ltima d&#233;cada&#44; una serie de cambios epidemiol&#243;gicos&#44; cl&#237;nicos&#44; etiol&#243;gicos y de resistencias a antibi&#243;ticos&#44; que obligan a replantear su abordaje terap&#233;utico&#46; En este documento&#44; dos de las principales sociedades de especialidades pedi&#225;tricas involucradas en el diagn&#243;stico y tratamiento de esta entidad&#44; como son la Sociedad Espa&#241;ola de Infectolog&#237;a Pedi&#225;trica y la Sociedad Espa&#241;ola de Neumolog&#237;a Pedi&#225;trica&#44; as&#237; como el Comit&#233; Asesor de Vacunas de la AEP&#44; proponen unas pautas consensuadas de tratamiento y prevenci&#243;n&#44; con el fin de proporcionar a todos los pediatras una gu&#237;a actualizada&#46; En esta primera parte del consenso&#44; se aborda el tratamiento de los pacientes sin enfermedades de base relevantes con NAC que no precisan ingreso hospitalario&#44; as&#237; como la prevenci&#243;n global de esta patolog&#237;a con vacunas&#46; En un siguiente documento se expondr&#225; el abordaje terap&#233;utico tanto de aquellos pacientes en situaciones especiales como de las formas complicadas de la enfermedad&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Moreno-P&#233;rez D&#44; Mart&#237;n AA&#44; Garc&#237;a AT&#44; Montaner AE&#44; Mulet JF&#44; Garc&#237;a JJG&#44; et al&#46; Neumon&#237;a adquirida en la comunidad&#58; tratamiento ambulatorio y prevenci&#243;n&#46; An Pediatr &#40;Barc&#41;&#46; 2015&#59;83&#58;439&#46;e1&#8211;439&#46;e7&#46;</p>"
      ]
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        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Los nombres de los componentes de las Sociedades est&#225;n relacionados en el anexo&#46;</p>"
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    ]
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            "apendice" => "<p id="par0295" class="elsevierStylePara elsevierViewall">The affiliation of the authors is as follows&#58;<elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix"
            "identificador" => "sec0095"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Adapted from P&#233;rez-Trallero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a></p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of antibiotics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage pf sensitive strains&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; in infections outside the central nervous system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#946;-Lactams&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin &#40;at high doses&#41;&#58; 98&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ampicillin&#58; 93&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Parenteral penicillin&#58; 99&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cephotaxime&#58; 99&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Oral cefuroxime&#58; 94&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Parenteral cefuroxime&#58; 99&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macrolides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Erythromycin&#44; clarithromycin&#44; azithromycin&#58; 75&#8211;79&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quinolones&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Levofloxacin&#58; 97&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Haemophilus influenzae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#946;-Lactams&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&#44; ampicillin&#44; penicillin&#58; 85&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macrolides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus pyogenes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#946;-lactams&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macrolides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Erythromycin&#44; clarithromycin&#44; azithromycin&#58; 65&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sensitivity of the main bacteria causing CAP in Spain &#40;data from the SAUCE-4 study&#41;&#46;</p>"
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        "etiqueta" => "Table 2"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Typical CAP &#40;with suspected or confirmed aetiology&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Name&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Posology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Current duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Oral amoxicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#8211;90<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; divided into 3 doses &#40;every 8<span class="elsevierStyleHsp" style=""></span>h&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 days&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Atypical CAP with confirmed aetiology or high suspicion of <span class="elsevierStyleItalic">Mycoplasma</span> or <span class="elsevierStyleItalic">Chlamydia&#46;</span> Most used macrolides</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Name&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Posology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Oral azithromycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 24<span class="elsevierStyleHsp" style=""></span>h &#40;maximum&#58; 500<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Oral clarithromycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; every 12<span class="elsevierStyleHsp" style=""></span>h &#40;maximum dose&#58; 1<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 days&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Respiratory Infections Work Group&#46; Spanish Society for Paediatric Infectious Diseases &#40;SEIP in Spanish&#41;&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>D Moreno-P&#233;rez&#44; J&#46;J&#46; Garc&#237;a Garc&#237;a&#44; C Rodrigo Gonzalo de Lliria&#44; J Ruiz Contreras and J Saavedra Lozano&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Spanish Society of Paediatric Pneumology &#40;SENP in Spanish&#41;&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>A Andr&#233;s Mart&#237;n&#44; A Escribano Montaner&#44; J Figuerola Mulet&#44; A Moreno-Gald&#243;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>D Moreno-P&#233;rez&#44; J Ruiz Contreras&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2014.10.011

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Year/Month	Html	Pdf	Total

2024 November	24	10	34
2024 October	118	61	179
2024 September	111	38	149
2024 August	118	64	182
2024 July	100	35	135
2024 June	110	41	151
2024 May	119	47	166
2024 April	107	38	145
2024 March	107	41	148
2024 February	108	33	141
2024 January	108	25	133
2023 December	116	21	137
2023 November	92	38	130
2023 October	97	63	160
2023 September	76	30	106
2023 August	67	17	84
2023 July	85	27	112
2023 June	74	31	105
2023 May	86	28	114
2023 April	71	23	94
2023 March	142	35	177
2023 February	79	21	100
2023 January	81	19	100
2022 December	85	28	113
2022 November	132	50	182
2022 October	70	39	109
2022 September	54	33	87
2022 August	81	91	172
2022 July	95	77	172
2022 June	98	45	143
2022 May	111	55	166
2022 April	96	49	145
2022 March	118	58	176
2022 February	206	51	257
2022 January	144	39	183
2021 December	102	55	157
2021 November	99	56	155
2021 October	109	47	156
2021 September	86	42	128
2021 August	54	44	98
2021 July	61	34	95
2021 June	62	44	106
2021 May	63	31	94
2021 April	199	82	281
2021 March	106	59	165
2021 February	72	25	97
2021 January	89	25	114
2020 December	66	53	119
2020 November	47	25	72
2020 October	53	15	68
2020 September	44	28	72
2020 August	28	25	53
2020 July	29	26	55
2020 June	63	19	82
2020 May	61	31	92
2020 April	74	24	98
2020 March	47	26	73
2020 February	33	30	63
2020 January	61	17	78
2019 December	44	31	75
2019 November	44	17	61
2019 October	49	23	72
2019 September	44	22	66
2019 August	49	26	75
2019 July	34	36	70
2019 June	64	38	102
2019 May	104	27	131
2019 April	112	56	168
2019 March	61	35	96
2019 February	79	36	115
2019 January	53	24	77
2018 December	62	37	99
2018 November	164	40	204
2018 October	530	71	601
2018 September	94	24	118
2018 August	4	0	4
2018 July	1	0	1
2018 June	6	0	6
2018 May	9	0	9
2018 April	35	0	35
2018 March	39	0	39
2018 February	17	0	17
2018 January	23	0	23
2017 December	32	0	32
2017 November	35	0	35
2017 October	22	0	22
2017 September	27	0	27
2017 August	23	0	23
2017 July	34	1	35
2017 June	25	13	38
2017 May	39	13	52
2017 April	35	17	52
2017 March	30	6	36
2017 February	32	15	47
2017 January	16	9	25
2016 December	21	13	34
2016 November	29	14	43
2016 October	58	13	71
2016 September	53	19	72
2016 August	44	12	56
2016 July	27	6	33

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