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Following the Guidelines: Not Always as Simple as it Seems :

September 25, 2018

As one of the most common pediatric illnesses, community acquired pneumonia (CAP) is a familiar and frequent diagnosis.

As one of the most common pediatric illnesses, community acquired pneumonia (CAP) is a familiar and frequent diagnosis. Though evidence-based guidelines published by the Infectious Diseases Society of America (IDSA) and Pediatric Infectious Diseases Society (PIDS) on the management of CAP do exist (Bradley et al Clin Infect Dis2011), significant practice variability still persists (Handy et al Pediatrics 2017, Brogan et al Pediatr Infect Dis J. 2012, Queen et al Pediatrics 2013).

In a recently released article in Pediatrics, Ambraggio et al (10.1542/peds.2018-0331) successfully demonstrate a methodology for increasing outpatient provider use of the aforementioned joint guidelines and examines the effects of such implementation. It has been well demonstrated that the publication of clinical practice guidelines often does not result in changes to physician behavior or if it does, it takes an extraordinarily long time to do so (Cabana et al JAMA 1999, Morris et al J R Soc Med 2011). The reasons for this are many but seem to center around lack of provider knowledge and familiarity (Fischer et al Healthcare 2016). Ambraggio et al’s study provides us with a practical means of bypassing such barriers and demonstrates that with time and education, the adoption of guidelines into clinical practice is possible.

Additionally, their study both affirms and questions aspects of these recommendations that were subsequently brought to light by increased provider adherence. For instance, their findings confirm the use of amoxicillin as first line therapy and further support the recommendation against the use of chest imaging, CBC and CRP testing to aid in diagnosis. However, their results indicate a potentially larger role for macrolide monotherapy that is not currently part of the guidelines. Ambraggio et al also suggest that the routine use of pulse oximetry provides no additional benefit as this intervention did not significantly increase the proportion of children detected with hypoxia as compared to its use in select cases. 

Though the importance of following clinical practice guidelines is hardly debatable, the barriers to doing so have the potential to stop many of us in our tracks. Ambraggio et al show us a means of averting these barriers on a large scale. Only with the implementation of practice recommendations can we fully assess their efficacy, since as in the case of the CAP guidelines, practical outcomes might further support or even contradict the original recommendations themselves. 


  1. Bradley, John S., et al. “The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.” Clinical Infectious Diseases, vol. 53, no. 7, 2011, doi:10.1093/cid/cir531.
  2. Handy, Lori K., et al. “Variability in Antibiotic Prescribing for Community-Acquired Pneumonia.” Pediatrics, vol. 139, no. 4, 2017, doi:10.1542/peds.2016-2331.
  3. Brogan, Thomas V., et al. “Variability in Processes of Care and Outcomes among Children Hospitalized with Community-Acquired Pneumonia.” The Pediatric Infectious Disease Journal, 2012, p. 1., doi:10.1097/inf.0b013e31825f2b10.
  4. Queen, M A, et al. “Comparative Effectiveness of Empiric Antibiotics for Community-Acquired Pneumonia.” Pediatrics, vol. 133, no. 1, 2013, doi:10.1542/peds.2013-1773d.
  5. Cabana, Michael D., et al. “Why Don't Physicians Follow Clinical Practice Guidelines?” Jama, vol. 282, no. 15, 1999, p. 1458., doi:10.1001/jama.282.15.1458.
  6. Morris, Zoë Slote, et al. “The Answer Is 17 Years, What Is the Question: Understanding Time Lags in Translational Research.” Journal of the Royal Society of Medicine, vol. 104, no. 12, 2011, pp. 510–520., doi:10.1258/jrsm.2011.110180.
  7. Fischer, Florian, et al. “Barriers and Strategies in Guideline Implementation—A Scoping Review.” Healthcare, vol. 4, no. 3, 2016, p. 36., doi:10.3390/healthcare4030036.
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