Community-Acquired Pneumonia Treatment Guidelines

Diagnostic Approach

The American Academy of Pediatrics recommends that routine chest radiographs are not necessary for confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting 1
Chest radiographs should be obtained in patients with suspected hypoxemia, significant respiratory distress, or those with failed initial antibiotic therapy, as recommended by the Infectious Diseases Society of America 1
Pulse oximetry should be performed in all children with pneumonia to assess for hypoxemia and guide decisions regarding site of care, according to the American Thoracic Society 1
For children requiring mechanical ventilation, tracheal aspirates should be obtained for Gram stain, culture, and viral pathogen testing at the time of endotracheal tube placement, as suggested by the Society of Critical Care Medicine 2, 1

The American Academy of Pediatrics recommends that preschool-aged children (< 5 years) with suspected bacterial pneumonia should receive oral amoxicillin 90 mg/kg/day in 2 doses 2, 3, 4
For school-aged children and adolescents (≥ 5 years) with suspected bacterial pneumonia, the Infectious Diseases Society of America recommends oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 2, 3
The American Academy of Pediatrics suggests that for children > 7 years with atypical pneumonia, doxycycline (2-4 mg/kg/day in 2 doses) is an alternative 5
For fully immunized children admitted to a hospital ward, the Infectious Diseases Society of America recommends ampicillin or penicillin G when local epidemiologic data show lack of substantial high-level penicillin resistance for invasive S. pneumoniae 3, 4

Children on adequate therapy should demonstrate clinical improvement within 48-72 hours, according to the American Thoracic Society 6, 7
If a child fails to improve or deteriorates within 48-72 hours after initiation of antibiotics, further investigation should be performed, as recommended by the Infectious Diseases Society of America 2, 1
Antiviral therapy should be administered as soon as possible to children with moderate to severe CAP consistent with influenza virus infection during widespread local circulation of influenza viruses, according to the Centers for Disease Control and Prevention 2, 3, 6
Follow-up chest radiographs should be obtained in children who fail to demonstrate clinical improvement or have progressive symptoms within 48-72 hours after starting antibiotics, as suggested by the American Academy of Pediatrics 2, 1, 4, 6

Children not responding after 48-72 hours require clinical reassessment, imaging evaluation, and consideration of alternative or resistant pathogens, as recommended by the Infectious Diseases Society of America 8
Clinical and laboratory assessment to determine severity and need for higher level of care is necessary for non-responders, according to the Infectious Diseases Society of America 8
Imaging evaluation, such as chest radiograph or ultrasound, to assess extent and progression of pneumonic or parapneumonic process is recommended for non-responders, as stated by the Infectious Diseases Society of America 8
Further microbiologic investigation to identify persistent pathogens, resistance, or secondary infection is required for non-responders, as suggested by the Infectious Diseases Society of America 8
For mechanically ventilated children, obtaining bronchoalveolar lavage (BAL) for Gram stain and culture is necessary, as recommended by the Infectious Diseases Society of America 8

Small parapneumonic effusions (≤10mm rim) can be managed with antibiotics alone without drainage, as recommended by the Infectious Diseases Society of America 8
Moderate effusions require pleural fluid culture by thoracentesis or chest tube if high respiratory compromise, according to the Infectious Diseases Society of America 8
Large effusions (>50% thorax opacified) require chest tube with fibrinolytics, with VATS reserved for non-responders, as stated by the Infectious Diseases Society of America 8
Antibiotic duration for parapneumonic effusions should be 2-4 weeks depending on adequacy of drainage and clinical response, as recommended by the Infectious Diseases Society of America 8