Community-acquired pneumonia in children

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Key Points

Non-severe community-acquired pneumonia (CAP) in a previously healthy child can be safely managed in the community.[1][9] Treatment involves empirical oral antibiotics (with high-dose amoxicillin the first-line option), together with advice on hydration and use of antipyretics, and provision of safety-netting information.[3][9][18]
Hospital admission is indicated for any child with severe pneumonia or CAP with suspected complications.[1][9] Base the assessment of severity on symptoms, signs, and risk factors for severe disease.[1][9]
Supplemental oxygen and/or intravenous fluid therapy may be needed, according to vital signs.[1][3][9] Any child who requires assisted ventilation or has oxygen saturation <92% despite supplemental oxygen requires an escalation of care to the intensive care unit (ICU).[1][9]
Parenteral antibiotic therapy is recommended for any child admitted to hospital for management of CAP, starting with an empirical regimen and switching to a targeted antibiotic if a pathogen is identified by microbiological investigation.[1] Protocols for antibiotic treatment of severe CAP vary, so check your local protocol. Evidence shows that oral therapy is safe and effective, if tolerated.[9][53][54]
Antivirals may have a role for specified subgroups of children with suspected or confirmed influenza-associated CAP, although the balance of benefits versus adverse effects remains the subject of debate. Guidelines vary, so check your local protocol. Oseltamivir is the antiviral of choice, and treatment initiated within 48 hours of symptom onset provides the optimum benefit.[1][55] If used, the antiviral is typically given alongside antibiotics because co-infection is common.
Any child receiving appropriate antimicrobial therapy should start to show clinical and laboratory signs of improvement within 48-72 hours.[1] Arrange prompt reassessment, and consider further investigations and an escalation of care setting, if this is not the case.[1]

General principles

Make a decision on the appropriate setting for care based on a clinical assessment of symptoms, signs, and risk factors for severe disease, together with any evidence of possible complications.[1][9]

Non-severe pneumonia in previously healthy children can be safely managed in the community.[1][9]
Refer to hospital for assessment and management if a child has severe pneumonia or pneumonia with suspected complications.
Look for any signs of sepsis.[2][9] See Sepsis in children.
For details on categorising severity of CAP and criteria for hospital admission, see Diagnosis - Approach.

Treatment of CAP in children with non-severe disease is empirical.

Most cases of childhood CAP are caused by viral pathogens. Microbiological investigations are not indicated for non-severe CAP, and it can be challenging to distinguish bacterial from viral aetiology based on clinical and radiological findings.[1][9][19]
Hence, the causative agent is not usually identified and empirical antibiotic therapy is the first-line treatment.

Antibiotic therapy principles

The recommendations provided here relate to empirical antibiotic choices for patients treated in the community and in hospital.

Antimicrobial recommendations may vary according to local susceptibility patterns. Please refer to your local protocol.
If a causative pathogen is identified, switch the patient to an organism-specific antibiotic regimen, guided by sensitivity tests.[9] Seek advice from your local microbiology team where needed.
If an atypical pathogen is suspected, empirical regimens differ from those recommended here. See Atypical pneumonia.

Give antibiotics to any child who has a clinical diagnosis of CAP.[1][3][9][18]

The only exception is a child <2 years old who has mild symptoms and is fully vaccinated (including with pneumococcal vaccine).[1][9] In these circumstances, the CAP is unlikely to be bacterial so do not prescribe antibiotics unless symptoms become more severe.[1][9]
In the UK, the National Institute for Health and Care Excellence (NICE) recommends starting antibiotic therapy within 4 hours of establishing a diagnosis. The choice of antibiotic is guided by severity of symptoms and signs; the risk, or presence, of any complications; local antimicrobial resistance and surveillance data (e.g., influenza and Mycoplasma pneumoniae infection rates); and any microbiological results.[18]

Oral antibiotics are safe and effective, if tolerated, even for severe CAP.[9][53][54]

Several large randomised controlled trials have shown that oral amoxicillin is non-inferior to a parenteral penicillin.[56][57][58]

In the absence of any guidelines recommending optimal duration, empirical antibiotic treatment has traditionally been given for 7-10 days.[1][3] However, evidence now suggests that a shorter course is likely to be sufficient in children with non-severe CAP who are treated as outpatients.[10] Check your local protocol.

In the US, the 2011 guideline published by the Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) states that 10-day treatment courses have been best studied, but evidence suggests that shorter courses may be equally effective, particularly for non-severe disease managed on an outpatient basis.[1]
One Cochrane review found no significant difference in outcomes when comparing a 3-day versus 5-day course of antibiotics for non-severe CAP in children aged 2-59 months in low-income countries.[59] A subsequent randomised controlled trial of clinically diagnosed CAP found that a 3-day course of amoxicillin was non-inferior to a 7-day course in children with clinically diagnosed CAP (although some participants had received prior antibiotic therapy).[60] Another randomised trial comparing a 5-day versus 10-day course of high-dose amoxicillin in 380 previously healthy children aged 6-71 months with non-severe CAP found that those treated with the shorter course had a similar clinical response and less colonisation with antibiotic-resistant bacteria.[61] A meta-analysis of nine randomised clinical trials including 11,143 children aged 2-59 months with non-severe CAP found that for the outcome of treatment failure, a 3-day course of antibiotic therapy was non-inferior to a 5-day course (risk ratio 1.01, 95% CI 0.91 to 1.12) and a 5-day course was non-inferior to a 10-day course (risk ratio 0.87, 95% CI 0.50 to 1.53).[62]
High-quality guidelines for CAP in children are inconsistent in their recommendations on duration of antibiotic therapy, varying from 3 to 10 days for uncomplicated disease, with longer courses for severe or complicated disease, CAP caused by certain specific organisms, and children with pre-existing comorbidities.[7] In the UK, NICE recommends a 5-day course, with treatment only continued if microbiological results suggest that a longer course is needed or the child is not clinically stable (i.e., fever in the past 48 hours, or >1 sign of clinical instability [systolic blood pressure <90 mmHg, heart rate >100 beats/minute, respiratory rate >24 breaths/minute, arterial oxygen saturation <90%, or PaO₂ <60 mmHg on room air]).[18]

Antiviral therapy

Guidelines vary on indications for antiviral therapy in children with assumed or confirmed influenza-associated CAP. Check your local protocol.

In the UK, hospital-based clinicians can prescribe oseltamivir or zanamivir (depending on age) for treatment of suspected or confirmed influenza at any time, but prescribing in the community is limited to periods when the influenza virus is circulating.[63][64][65]
The World Health Organization (WHO) influenza guideline recommends against the use of oseltamivir, zanamivir, and other antivirals in patients with non-severe influenza, with the only exception being a conditional recommendation, based on low-quality evidence, to consider baloxavir for non-severe influenza in patients at high risk of progression to severe disease.[66] The WHO also makes a conditional recommendation, based on low-quality evidence, for use of oseltamivir to treat patients with severe influenza.[66]
US guidelines recommend early initiation of antiviral therapy for any child with assumed or confirmed influenza-related CAP if the child requires hospitalisation, or is treated as an outpatient and is progressively worsening or is at high risk for complications.[55][67] Antiviral therapy can be considered for other children treated as outpatients after consideration of benefits versus risks and provided it can be initiated within 48 hours of symptom onset.[55][67]

Oseltamivir is the usual first-line antiviral.[55][63] However, there has been extensive debate over the use of oseltamivir and whether or not it does reduce complications in otherwise healthy children.[68][69]

In practice, many clinicians find that the increased risk of adverse effects (e.g., nausea and vomiting) in children outweighs any benefits.

If an antiviral is used, it is generally used alongside antibiotic treatment because of the high incidence of co-infection (although note that the WHO recommends against use of antibiotics for patients with non-severe influenza and low probability of bacterial co-infection).[66]

For more details, see Influenza infection.

Treatment in the community

The key elements of outpatient management for non-severe CAP are initiation of oral antibiotics, together with advice on hydration and use of an antipyretic.[9]

Ensure that appropriate safety-netting advice is provided to carers, with information on managing fever, preventing dehydration, and identifying deterioration; fever may be treated with an antipyretic (e.g., paracetamol, ibuprofen). Advise them to bring the child for reassessment if any of the following features is present:[3][9][18]

A high swinging or persistent fever that continues >48 hours after antibiotic treatment has started.[9]
Any signs of harder work of breathing, such as a fast respiratory rate or chest recession.[9]
Breathing makes the child agitated and distressed.[9]
Symptoms do not start to improve within 3 days.[18]

If the child does not respond to oral outpatient antimicrobial therapy and has developed signs of respiratory distress, arrange hospital admission.[1]

Choice of antibiotic

High-dose oral amoxicillin is the first-line antibiotic for any previously healthy child ≥3 months of age with non-severe CAP who is being managed in the community.[1][9][18] Amoxicillin/clavulanate is an alternative option.[1][9]

Amoxicillin provides appropriate coverage for Streptococcus pneumoniae, the most common typical bacterial pathogen and one that if inadequately treated may lead to serious sequelae.[1]
Consider adding a macrolide (e.g., azithromycin, clarithromycin, erythromycin) if there is a poor response, with no improvement after 48 hours.[3][9] Note that macrolides have been associated with altered cardiac conduction (e.g., QT interval prolongation, arrhythmias including torsades de pointes).
Amoxicillin/clavulanate is recommended for CAP associated with influenza.[9]
First-line alternatives for children who are allergic to penicillins include levofloxacin, linezolid, a second- or third-generation cephalosporin (e.g., cefprozil, cefpodoxime), or a macrolide.[1][10][18]
- Systemic fluoroquinolone antibiotics, such as levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[70]
- Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

The US paediatric CAP guideline does not cover infants <3 months of age.[1] The UK National Institute of Health and Care Excellence recommends:[18]

Oral amoxicillin for non-severe CAP for infants aged 1-3 months.
Referral to a paediatric specialist for advice on the appropriate antibiotic regimen for any child <1 month of age.
In practice, there is a low threshold for referring any infant <3 months of age to hospital for assessment and treatment.

Inpatient management: supportive care

Ensure ongoing monitoring of fever, respiratory rate, oxygen saturation, and respiratory distress (e.g., signs of chest retractions, grunting, nasal flaring).[1]

Look for any signs of sepsis and manage or escalate to senior colleagues accordingly. See Sepsis in children.
If there is increased work of breathing, ensure continuous monitoring of oxygen saturation.[1]

If the child is hypoxaemic, provide supplemental oxygen by nasal cannula or face mask (or a head box if needed for an infant).[1][3][9]

In most cases this will be sufficient to restore oxygen saturation.[1] Target an oxygen saturation >92%.[9]
If a child requires FiO₂ ≥0.50 to maintain saturation >92%, admit them to a unit with capability for continuous cardiorespiratory monitoring.

Give fluid therapy if the child is unable to maintain their fluid intake due to breathlessness, fatigue, or vomiting. Patients who are vomiting or are severely ill may also need intravenous fluids.[3][9] Use isotonic intravenous fluids.[2]

Measure electrolytes (in particular sodium and potassium), urea, and creatinine at baseline.[9]
Hyponatraemia (serum sodium <135 mEq/L) is common in children admitted to hospital with respiratory infection. One retrospective analysis of 312 children admitted with CAP found that hyponatraemia was present in 33% and was correlated with disease severity.[71] Hence, use isotonic rather than hypotonic intravenous fluid to maintain hydration.[2][72]

Criteria for ICU admission

The US PIDS/IDSA guideline recommends to refer to paediatric ICU if a child:[1]

Requires invasive ventilation
Has oxygen saturation <92% on fraction of inspired oxygen (FiO₂) ≥50%.

The US guideline further recommends to arrange admission to an ICU or a unit with continuous cardiorespiratory monitoring capability if a child:[1]

Requires use of non-invasive positive pressure ventilation (e.g., continuous positive airway pressure [CPAP] or bilevel positive airway pressure)
Has impending respiratory failure (e.g., as indicated by grunting)
Has sustained tachycardia, inadequate blood pressure, or need for pharmacological support of blood pressure or perfusion
Has altered mental status as a result of pneumonia, whether due to hypercarbia or hypoxaemia.

In the UK, the British Thoracic Society guideline recommends referral to ICU for:[9]

Development of respiratory failure requiring assisted ventilation
Pneumonia complicated by sepsis
Failure to maintain oxygen saturation >92% with FiO₂ >60%
Clinical features of shock
Increasing respiratory and heart rates with severe respiratory distress and exhaustion, with or without raised pCO₂
Recurrent apnoea or slow, irregular breathing.

Any child with complicated pneumonia must be treated in a centre with expertise in this area.[2]

Antibiotic therapy in hospital

For management of CAP in hospitalised children:[3]

Treat with oral or parenteral antibiotics according to local protocols and criteria. In the US, parenteral therapy is recommended.[1][8]
Order microbiological investigations and imaging as indicated by symptoms/signs and any suspicion of complicated CAP. For more details, see Diagnosis - Approach.
Switch to a targeted antibiotic if a pathogen is identified by microbiological investigation.
Re-assess after 48 hours to check for improvement in symptoms and signs.
Consider escalation to a specialist or tertiary care centre if there is significant clinical deterioration.

Choice of empirical antibiotics for children <3 months of age

The US PIDS/IDSA guideline does not cover infants <3 months of age. In the UK, NICE recommends referring any infant <1 month of age to a paediatric specialist for a decision on the choice of antibiotic regimen.[18]

The following may be appropriate first-line options for empirical antibiotic therapy in children <3 months of age, but the decision will be individualised after specialist discussion, taking account of local resistance patterns:[8]

In infants <1 month of age, ampicillin (amoxicillin may be preferred in the UK and some other countries) plus an aminoglycoside (e.g., gentamicin) or cefotaxime.[8] If the mother did not have routine antenatal screening for chlamydia, consider the possibility of Chlamydia trachomatis pneumonia in the infant.[8] If confirmed, azithromycin is the recommended treatment.[1]
In the UK, NICE recommends amoxicillin/clavulanate for any child aged 1 month or older who has severe symptoms.[18] Other options that might be considered in infants aged 1-3 months include ampicillin or cefotaxime.[8]

Choice of empirical antibiotics for children ≥3 months of age

Recommendations on choice of antibiotic therapy and route of administration vary, so check your local protocol.

In the US, the PIDS/IDSA 2011 guideline recommends the following antibiotic regimens for children ≥3 months of age with CAP who are treated in hospital:[1]

Children with suspected bacterial CAP that is serious enough to warrant hospitalisation should be routinely treated with parenteral antibiotics to ensure reliable blood and tissue concentrations.
High-dose ampicillin or benzylpenicillin is recommended first-line for any previously healthy, fully immunised child with presumed bacterial CAP (assuming there are no local reports of high-level penicillin resistance for invasive Streptococcus pneumoniae). A third-generation cephalosporin (e.g., ceftriaxone, cefotaxime) is an alternative option.
Empirical therapy with a third-generation cephalosporin is recommended first-line if one or more of the following apply: the child is not fully immunised, or there is local evidence of significant penicillin resistance for invasive S pneumoniae, or the child has life-threatening infection, including those with empyema. Levofloxacin is an alternative option in these patients.
Clindamycin or vancomycin may be added if methicillin-resistant Staphylococcus aureus (MRSA) is suspected.

In the UK:

Use amoxicillin as the first-line antibiotic for most children.[9][18]
- Alternatives recommended by the British Thoracic Society (BTS) are amoxicillin/clavulanate, cefaclor, or a macrolide.[9] The BTS recommends adding a macrolide if there is no response to first-line empirical therapy.[9]
If the child has high-severity CAP, NICE recommends amoxicillin/clavulanate first-line.[18]
Only use intravenous antibiotics if a child is unable to tolerate oral fluids (e.g., because of vomiting) and/or has signs of sepsis or complicated pneumonia. The recommended options include amoxicillin, amoxicillin/clavulanate, cefotaxime, or ceftriaxone.
- Review the need for intravenous antibiotics by 48 hours. Switch to oral administration when there is clear evidence of improvement.[18]

Non-responding pneumonia

Arrange prompt reassessment and order further investigations for any child whose condition deteriorates after hospital admission and initiation of appropriate antimicrobial therapy.[1][9]

This is particularly important if there is increased work of breathing or the child becomes distressed or agitated.[9]

Any child receiving appropriate antimicrobial therapy should show clinical and laboratory signs of improvement within 48-72 hours. If this is not the case:[1]

Consider an escalation of care setting
Repeat chest radiography and consider other imaging to assess the extent and progression of the pneumonic or parapneumonic processes
Consider further investigations to determine whether the initial pathogen is persistent or has developed resistance to the antimicrobial agent(s) used, or if there is a new secondary infection.

Consider the following factors when assessing whether a child is a non-responder at 48-72 hours:[1]

Vital signs and oxygen saturation
- Persistence or increase in the general fever pattern.[9]
- Increased respiratory rate, grunting, chest retractions, cyanosis.
- Persistent increased heart rate.
- Oxygen saturation <90% on room air or need for supplemental oxygen or ventilation.
Systemic or focal symptoms or signs
- Change in mental status.
- Chest pain.
- Inability to maintain oral intake and hydration.
- Extent of abnormal or absent breath sounds on auscultation or dullness in response to percussion.
Laboratory and/or radiological results
- Peripheral white blood cells (WBC), including total count and % of immature forms of neutrophils.
- Inflammatory markers (e.g., procalcitonin, C-reactive protein [CRP]).
- Isolation of a resistant pathogen.
- Imaging evidence (chest x-ray, ultrasound, or computed tomography [CT]) of increased parenchymal involvement, presence of or increase in pleural fluid, development of pulmonary abscess, or necrotising pneumonia.

Complicated pneumonia

Local complications of CAP consist of one or more of parapneumonic effusion, empyema, necrotising pneumonia, or lung abscess.[2]

Early detection of complicated pneumonia is crucial.
Be aware that factors associated with complicated CAP in previously healthy children include: age <2 years, long pre-hospital duration of fever, asymmetrical chest pain at presentation, high acute phase reactants, and low WBC count, although these may be confounded by reverse causation.[2]
Common causative pathogens are Streptococcus pneumoniae and Staphylococcus aureus. However, microbiological diagnosis of complicated CAP is challenging. Blood cultures should ideally have been collected prior to starting antibiotics, although diagnostic yield is low.[2]
Pleural fluid analysis is recommended if available. Molecular diagnostic tests are a major advance, with polymerase chain reaction (PCR) more sensitive than culture to detect pathogens in children with complications of CAP. Arrange imaging with chest x-ray and ultrasound to assess the lung parenchyma and identify pleural fluid. CT scanning is not usually indicated.[2][19] For more detail, see Diagnosis - Approach.
Complicated pneumonia is becoming more frequent.[19] One study of children hospitalised for CAP in the US found an incidence rate above 13% for pleural effusion/empyema, pneumothorax, lung abscess, bronchopleural fistula, and/or necrotising pneumonia.[4]

Complicated community-acquired pneumonia (CCAP) is treated with an extended course of antibiotics. Interventional procedures may sometimes be needed.[2][73] The clinical course of CCAP can be prolonged, especially for necrotising pneumonia, but children usually do recover completely.[2]

In the case of pleural effusion, early treatment with appropriate antibiotics might prevent progression to empyema.
Antibiotic treatment alone is usually sufficient in children with small parapneumonic effusions, no mediastinal shift, and no respiratory compromise.
Antibiotics are also effective in treating necrotising pneumonia, even if severe cavitation is present.
In most children with lung abscesses, a prolonged antibiotic course is usually effective.
For more details on specific complications, see Complications.

Use of this content is subject to our disclaimer