Treatment of Community-Acquired Pneumonia in Children

Outpatient Management

For a child with community-acquired pneumonia, amoxicillin should be used as first-line outpatient therapy at a dose of 90 mg/kg/day in two divided doses for 5-7 days, as recommended by the American Academy of Pediatrics 1, 2
A child should be well-appearing, able to maintain hydration, and have reliable caregivers to be eligible for outpatient management 3
Oxygen saturation should be >90% on room air for outpatient management 1

Moderate to severe respiratory distress, such as increased work of breathing, grunting, or nasal flaring, requires hospitalization 3, 1
Oxygen saturation <90% on room air is an indication for hospitalization 1
Inability to maintain oral hydration requires hospitalization 3
Failed outpatient therapy is an indication for hospitalization 2
Complicated pneumonia, such as pleural effusion, empyema, or necrotizing pneumonia, requires hospitalization 2

Amoxicillin 90 mg/kg/day divided twice daily (maximum 4g/day) for 5-7 days is the recommended first-line therapy for outpatient treatment of community-acquired pneumonia in children, according to the Infectious Diseases Society of America 1
For penicillin allergy, Clindamycin or a macrolide (azithromycin) can be used as alternative therapies 3
Ampicillin or penicillin G can be used for fully immunized children requiring inpatient therapy 1
Ceftriaxone or cefotaxime can be used for children not fully immunized or in areas with high pneumococcal resistance 1
Vancomycin or clindamycin can be added if MRSA is suspected 1

Blood cultures are generally not necessary for mild outpatient community-acquired pneumonia, as stated by the Infectious Diseases Society of America 3
For hospitalized patients, blood cultures should be obtained before starting antibiotics, as recommended by the American Academy of Pediatrics 2

Clinical improvement should be seen within 48-72 hours of starting appropriate antibiotics, according to the Infectious Diseases Society of America 4, 2
Follow-up within 48-72 hours of diagnosis is recommended to ensure improvement, as stated by the American Academy of Pediatrics 3
Routine follow-up chest radiographs are not necessary in children who recover uneventfully, as recommended by the American Academy of Pediatrics 2

Small parapneumonic effusions (<10mm rim) can be managed with antibiotics alone, according to the Infectious Diseases Society of America 4, 5
Moderate to large effusions may require drainage, especially with respiratory compromise, as stated by the American Thoracic Society 4, 5
Options for drainage include chest tube placement (with or without fibrinolytics) or video-assisted thoracoscopic surgery (VATS), as recommended by the Society of Thoracic Surgeons 5

Failure to reassess after 48-72 hours if no clinical improvement is a common pitfall, as stated by the Infectious Diseases Society of America 4
Unnecessary chest radiographs for follow-up in children who are clinically improving should be avoided, as recommended by the American Academy of Pediatrics 2

Pulse oximetry should be performed in all children with suspected pneumonia to guide site-of-care decisions, as recommended by the Infectious Diseases Society of America 6, 7
Chest radiographs should be obtained in patients with suspected hypoxemia, significant respiratory distress, or failed initial therapy, according to the Infectious Diseases Society of America 6, 7
Posteroanterior and lateral views are recommended when imaging is indicated, as suggested by the Infectious Diseases Society of America 6, 7
Complete blood count is not routinely necessary for outpatients but should be obtained for severe pneumonia, as recommended by the Infectious Diseases Society of America 6, 7
Acute-phase reactants (ESR, CRP, procalcitonin) cannot be used as the sole determinant to distinguish viral from bacterial CAP, according to the Infectious Diseases Society of America 6, 7

Children not responding after 48-72 hours require reassessment with clinical evaluation, imaging, and consideration of alternative pathogens or complications, as recommended by the Infectious Diseases Society of America 8, 9
Routine follow-up chest radiographs are not necessary in children who recover uneventively, according to the Infectious Diseases Society of America 7

Chest radiographs (posteroanterior and lateral) should be obtained in all hospitalized patients to document infiltrates and identify complications, as recommended by the Infectious Diseases Society of America 6, 7

For children ≥5 years with signs suspicious for Mycoplasma pneumoniae (gradual onset, prominent cough, minimal fever), a macrolide should be considered, as suggested by the Infectious Diseases Society of America 6
Diagnostic testing for Chlamydophila pneumoniae is not recommended as reliable tests do not currently exist, according to the Infectious Diseases Society of America 6