Implementation of an Inpatient Clinical Pathway for the Treatment of Community Acquired Pneumonia (CAP) in Pediatric Patients; Does it work?
Authors: Craven Alexis T , Covington Kelly , Al-Sayyed Ban 
Published: January 2025

Abstract

Corresponding Author: Alexis T. Craven, PharmD, 2160 S. 1st Ave. Maywood, IL 60153, 708-334-6489, Alexis.craven@luhs.org
Alternate Corresponding Author(s): Kelly Covington, BCPS, BCPPS, Loyola University Medical Center, Maywood, United States of America, 2160 S. 1st Ave. Maywood, IL 60153, 708-216-5667, Kelli.covington@luhs.org; Ban Al-Sayyed, MD, Loyola University Medical Center, Maywood, United States of America, 2160 S. 1st Ave. Maywood, IL 60153, 309-713-5363, ban.al-sayyed @lumc.edu
No conflicts of interest

Background
Community-acquired pneumonia (CAP) in pediatric patients is a common and potentially serious respiratory infection that affects children in community settings. It is primarily caused by viral or bacterial pathogens, with Streptococcus pneumoniae and respiratory syncytial virus (RSV) being leading culprits. Vaccination, particularly with the streptococcus pneumonia and Haemophilus influenzae type b, plays a vital role in preventing CAP and in the treatment approach in pediatric patients. Currently, the American Academy of Pediatrics (AAP) guidelines recommend treating patients admitted to the hospital with mild CAP who are fully vaccinated with ampicillin or penicillin G and patients who are not fully vaccinated with ceftriaxone. Because guideline-directed therapy for mild CAP was not consistently followed at Loyola University Medical Center (LUMC), a pathway was developed to aid healthcare providers in classifying and managing pediatric patients with CAP.

Methods
This study is a single-center, observational, retrospective, cohort study conducted on patients admitted to the general pediatric and pediatric intensive care units with a diagnosis of CAP from January 2022 to December 2023 at LUMC Children’s Hospital. The purpose of this study is to evaluate the implementation of the inpatient clinical pathway for community acquired pneumonia (CAP) in infants greater than 60 days to pediatric patients less than 18 years old at LUMC Children’s Hospital. The primary outcome was the effectiveness of the pathway in reduction of ceftriaxone prescribing in pediatric patients with CAP.

Results
A total of 146 patients were included, with 87 in the pre-pathway group and 59 in the post-pathway group. While there were notable shifts in racial demographics post-pathway, with a significant increase in Hispanic representation (39.1% to 67.8%, p=0.001) and a significant decrease in Caucasian representation (39.1% to 15.3%, p=0.003), there were no significant differences observed between gender distribution, vaccination status, or prevalence of penicillin allergies in the two groups. Notably, there was an increase in the utilization of infectious disease consultation (1.1% pre-pathway vs. 10.2% post-pathway, p = 0.018) and MRSA nares screening (3.4% pre-pathway vs. 61% post-pathway, p &lt; 0.01). Additionally, there was a statistically significant decrease in the empirical use of ceftriaxone upon admission to the inpatient units (86.2% pre-pathway vs. 54.2% post-pathway, p &lt; 0.01). Adherence to clinical pathways, particularly on admission to the general pediatric (37.9% pre-pathway vs. 89.7% post-pathway, P &lt; 0.01) and pediatric intensive care unit (PICU) (13.8% pre-pathway vs. 33.3% post-pathway, P = 0.031) also improved post- pathway implementation.

Conclusion
The implementation of the inpatient clinical pathway for CAP at LUMC Children’s Hospital has demonstrated significant enhancements in patient management practices, particularly in the realm of antibiotic stewardship. The observed improvements in the utilization of infectious disease consultation and adherence to the pathway reduced empirical use of ceftriaxone, which highlights the pathway’s pivotal role in promoting judicious antibiotic prescribing. By providing a standardized approach to CAP management, this pathway not only improves clinical outcomes but also contributes to antibiotic stewardship efforts, ensuring optimal treatment while minimizing antibiotic resistance and associated risks. These findings emphasize the importance of integrating clinical pathways, specifically tailored for CAP, in healthcare settings to advance antibiotic stewardship practices and enhance overall patient care.