Community-acquired pneumonia in children

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

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

outpatient (nonsevere)

1st line – supportive care

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1st line –

supportive care

Nonsevere CAP in a previously healthy child can be safely managed in the community.[1][9]

Ensure appropriate safety-netting advice is provided to caregivers, with information on managing fever, preventing dehydration, and identifying deterioration. Advise them to bring the child for reassessment if any of the following features is present: a high swinging or persistent fever that continues >48 hours after antibiotic treatment has started; any signs of harder work of breathing, such as a fast respiratory rate or chest recession; breathing makes the child agitated and distressed; symptoms do not start to improve within 3 days.[3][9][17]

Fever may be treated with an antipyretic (e.g, acetaminophen, ibuprofen). Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may cause cardiovascular, renal, and gastrointestinal adverse effects. Use the lowest effective dose for the shortest treatment duration possible.

Doses recommended here are for children. Adolescents may receive pediatric or adult doses depending on the drug, the patient's age and weight, and clinical factors. Consult your local drug information source for dose recommendations for adolescents.

Primary options

acetaminophen: neonates: consult specialist for guidance on dose; infants and children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; children ≥12 years of age: 325-650 mg orally every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: children ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Plus – empiric oral antibiotic therapy

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Plus –

empiric oral antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Give antibiotics to any child who has a clinical diagnosis of CAP.[1][3][9][17] The only exception is a child <2 years of age who has mild symptoms and is fully vaccinated (including with pneumococcal vaccine); in these circumstances, the CAP is unlikely to be bacterial so do not prescribe antibiotics unless symptoms become more severe.[1][9]

Treatment of CAP in children with nonsevere disease is empiric. Microbiologic tests are not indicated.[1][9][18]

High-dose oral amoxicillin is the first-line antibiotic for any previously healthy child ≥3 months of age with nonsevere CAP who is being managed in the community.[1][9][17] Amoxicillin provides appropriate coverage for Streptococcus pneumoniae, the most common typical bacterial pathogen.[1]

Amoxicillin/clavulanate is an alternative option.[1][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 (e.g., azithromycin, clarithromycin, erythromycin) (although bear in mind the very high rates of resistance of S pneumoniae to macrolides in the US).[1][10][17]

Consider adding a macrolide if there is a poor response, with no improvement after 48 hours.[3][9]

The US pediatric CAP guideline does not cover infants <3 months of age but states that infants in that age group are generally admitted to the hospital for initial management. The UK National Institute for Health and Care Excellence (NICE) recommends oral amoxicillin for nonsevere CAP for infants ages 1-3 months and referral to a pediatric specialist for advice on the appropriate antibiotic regimen for any child <1 month of age.[17] In practice, there is a low threshold for referring any infant <3 months of age to the hospital for assessment and treatment.

Macrolides have been associated with altered cardiac conduction (e.g., QT interval prolongation, arrhythmias including torsades de pointes).

Systemic fluoroquinolone antibiotics 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; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[66] 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.

Check your local protocol for advice on the duration of antibiotic therapy. Empiric antibiotic treatment has traditionally been given for 7-10 days.[1][3] However, evidence now suggests that a shorter course is likely sufficient in children with nonsevere CAP who are treated as outpatients.[10] One Cochrane review found no significant difference in outcomes when comparing a 3-day versus 5-day course of antibiotics for nonsevere CAP in children ages 2-59 months in low-income countries.[58] A subsequent randomized controlled trial of clinically diagnosed CAP found that a 3-day course of amoxicillin was noninferior to a 7-day course in children with clinically diagnosed CAP (although some participants had received prior antibiotic therapy).[59] Another randomized trial comparing a 5-day versus 10-day course of high-dose amoxicillin in 380 previously healthy children ages 6-71 months with nonsevere CAP found that those treated with the shorter course had a similar clinical response and less colonization with antibiotic-resistant bacteria.[60] A meta-analysis of nine randomized clinical trials including 11,143 children ages 2-59 months with nonsevere CAP found that for the outcome of treatment failure, a 3-day course of antibiotic therapy was noninferior to a 5-day course (risk ratio 1.01, 95% CI 0.91 to 1.12) and a 5-day course was noninferior to a 10-day course (risk ratio 0.87, 95% CI 0.50 to 1.53).[61]

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/or an escalation of care setting if this is not the case.[1]

Primary options

amoxicillin: children 1-3 months of age: consult specialist for guidance on dose; children ≥3 months of age: 90 mg/kg/day orally given in 2 divided doses, maximum 4000 mg/day

amoxicillin: children ≥3 months of age: 90 mg/kg/day orally given in 2 divided doses, maximum 4000 mg/day

-- AND --

azithromycin: children ≥3 months of age: 10 mg/kg (maximum 500 mg/dose) orally once daily on day 1, followed by 5 mg/kg (maximum 250 mg/dose) once daily

clarithromycin: children ≥3 months of age: 7.5 mg/kg orally twice daily, maximum 500 mg/dose

erythromycin base: children ≥3 months of age: 10 mg/kg orally four times daily, maximum 500 mg/dose

Secondary options

amoxicillin/clavulanate: children ≥3 months of age and <40 kg body weight: 90 mg/kg/day orally given in 2 divided doses, maximum 4000 mg/day; children ≥3 months of age and ≥40 kg body weight: 2000 mg orally (extended-release) twice daily

-- AND --

azithromycin: children ≥3 months of age: 10 mg/kg (maximum 500 mg/dose) orally once daily on day 1, followed by 5 mg/kg (maximum 250 mg/dose) once daily

clarithromycin: children ≥3 months of age: 7.5 mg/kg orally twice daily, maximum 500 mg/dose

erythromycin base: children ≥3 months of age: 10 mg/kg orally four times daily, maximum 500 mg/dose

Tertiary options

levofloxacin: children ≥6 months of age: 16-20 mg/kg/day orally given in 2 divided doses, maximum 750 mg/day; children ≥5 years of age: 8-10 mg/kg orally once daily, maximum 750 mg/day

linezolid: children ≥3 months of age: 10 mg/kg orally three times daily, maximum 600 mg/dose

cefprozil: children ≥6 months of age: 7.5 to 15 mg/kg orally twice daily, maximum 500 mg/dose

cefpodoxime proxetil: children ≥3 months of age: 5 mg/kg orally twice daily, maximum 200 mg/dose

azithromycin: children ≥3 months of age: 10 mg/kg (maximum 500 mg/dose) orally once daily on day 1, followed by 5 mg/kg (maximum 250 mg/dose) once daily

clarithromycin: children ≥3 months of age: 7.5 mg/kg orally twice daily, maximum 500 mg/dose

erythromycin base: children ≥3 months of age: 10 mg/kg orally four times daily, maximum 500 mg/dose

Consider – antiviral therapy

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Consider –

antiviral therapy

Treatment recommended for SOME patients in selected patient group

The American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC) recommend early initiation of antiviral therapy for any child with assumed or confirmed influenza-related CAP who is treated as an outpatient and who either has progressively worsening symptoms or is at high risk for complications (regardless of symptom severity).[54][62] For other children treated as outpatients for assumed or confirmed influenza-related CAP, antiviral therapy can be considered following discussion of benefits/risks with parents or caregivers but only if it can be initiated within 48 hours of symptom onset.[54][62]

Oral oseltamivir is recommended as the antiviral of choice by the AAP.[54] Depending on the child's age, other options may include inhaled zanamivir or oral baloxavir.[54]

However, there has been extensive debate over the use of antivirals, in particular whether or not oseltamivir does reduce complications in otherwise healthy children.[63][64] The World Health Organization (WHO) influenza guideline recommends against the use of oseltamivir, zanamivir, and other antivirals in patients with nonsevere influenza, with the only exception being a conditional recommendation, based on low-quality evidence, to consider baloxavir for nonsevere influenza in patients at high risk of progression to severe disease.[65] The WHO also makes a conditional recommendation, based on low-quality evidence, for use of oseltamivir to treat patients with severe influenza.[65] In practice, many clinicians find that in children the increased risk of adverse effects (e.g., nausea and vomiting) outweighs any benefits. For more details, see Influenza infection.

If an antiviral is used, it is generally used alongside antibiotic treatment because of the high incidence of coinfection (although note that the WHO recommends against use of antibiotics for patients with nonsevere influenza and low probability of bacterial coinfection).[65]

poor response to oral antibiotic therapy or <6 months of age

Consider – inpatient management

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Consider –

inpatient management

Treatment recommended for SOME patients in selected patient group

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

The US pediatric CAP guideline states that infants <3 months of age with CAP are generally admitted to the hospital, and recommends to consider hospital admission for any child ages 3-6 months who has suspected bacterial CAP.[1]

inpatient (severe)

1st line – supportive care

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1st line –

supportive care

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] Look for any signs of sepsis. (See Sepsis in children.)[2][9] For details on categorizing severity of CAP and criteria for hospital admission, see Diagnosis approach. The US pediatric CAP guideline also states that infants <3 months of age with CAP are generally admitted to the hospital, and recommends to consider hospital admission for any child ages 3-6 months who has suspected bacterial CAP.[1]

Ensure ongoing monitoring of fever, respiratory rate, oxygen saturation, and respiratory distress (e.g., signs of chest retractions, grunting, nasal flaring).[1] If there is increased work of breathing, ensure continuous monitoring of oxygen saturation and/or measure arterial blood gas.[1] Look for any signs of sepsis and manage or escalate to senior colleagues accordingly. See Sepsis in children.

If the child is hypoxemic, 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]

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 fluid.[2] Measure electrolytes (in particular, sodium and potassium), BUN, and creatinine at baseline.[9] Hyponatremia (serum sodium <135 mEq/L) is common in children admitted to the hospital with respiratory infection. One retrospective analysis of 312 children admitted with CAP found hyponatremia was present in 33% and was correlated with disease severity.[67] Hence, use isotonic rather than hypotonic intravenous fluid to maintain hydration.[2][68]

Criteria for escalation to the intensive care unit (ICU) vary, so seek specialist advice and/or check your local protocol.

The Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) guideline recommends referral to a pediatric ICU if a child requires invasive ventilation or has oxygen saturation <92% on fraction of inspired oxygen (FiO₂) ≥50%.[1] It further recommends to arrange admission to an ICU or a unit with continuous cardiorespiratory monitoring capability if a child: requires use of noninvasive 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 pharmacologic support of blood pressure or perfusion; or has altered mental status as a result of pneumonia, whether due to hypercarbia or to hypoxemia.[1]

Primary options

<1 month of age

Plus – empiric antibiotic therapy

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Plus –

empiric antibiotic therapy

Treatment recommended for ALL patients in selected patient group

The choice of empiric antibiotic regimen, route of administration, and duration of therapy for an infant in this age group is individualized after specialist discussion.[17]

Appropriate options might include ampicillin (amoxicillin may be preferred in the UK and some other countries) plus an aminoglycoside (e.g., gentamicin) or cefotaxime.[8]

If an atypical pathogen is suspected, empiric regimens differ from those recommended here. See Atypical pneumonia.

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

For more information on factors to consider when assessing whether a child is a nonresponder, see Management approach.

Primary options

ampicillin: consult specialist for guidance on neonatal dose

amoxicillin: consult specialist for guidance on neonatal dose

-- AND --

gentamicin: consult specialist for guidance on neonatal dose

cefotaxime: consult specialist for guidance on neonatal dose

Consider – antiviral therapy

Back

Consider –

antiviral therapy

Treatment recommended for SOME patients in selected patient group

The American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC) recommend early initiation of antiviral therapy for any child who is hospitalized with assumed or confirmed influenza-related CAP. Oral oseltamivir is the treatment of choice for this age group.[54][62]

However, there has been extensive debate over the use of oseltamivir and whether or not it does reduce complications in otherwise healthy children.[63][64] The World Health Organization (WHO) influenza guideline recommends against the use of oseltamivir in patients with nonsevere influenza but makes a conditional recommendation, based on low-quality evidence, for use of oseltamivir to treat patients with severe influenza.[65]

In practice, many clinicians find that the increased risk of adverse effects (e.g., nausea and vomiting) in children outweighs the benefits. For more details, see Influenza infection.

Consider – switch to pathogen-directed antibiotic therapy

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Consider –

switch to pathogen-directed antibiotic therapy

Treatment recommended for SOME patients in selected patient group

If a causative pathogen is identified by microbiologic testing, switch the patient to an organism-specific antibiotic regimen, guided by sensitivity tests.[9]

Seek advice from your local microbiology team where needed.

1-3 months of age

Plus – empiric antibiotic therapy

Back

Plus –

empiric antibiotic therapy

Treatment recommended for ALL patients in selected patient group

The choice of empiric antibiotic regimen, route of administration, and duration of therapy will vary according to local guidelines and susceptibility patterns. Please refer to your local protocol.

In the US, parenteral therapy is recommended.[1][8] The Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) guideline does not cover infants ages <3 months. Amoxicillin/clavulanate is the recommended first-line option according to UK guidelines, but it is not available as a parenteral formulation in the US.[17] Other options include ampicillin or cefotaxime.[8] Patients on intravenous therapy may be switched to a suitable oral regimen when possible to complete the course.

If an atypical pathogen is suspected, empiric regimens differ from those recommended here. See Atypical pneumonia.

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

For more information on factors to consider when assessing whether a child is a nonresponder, see Management approach.

Primary options

ampicillin: 100-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day

cefotaxime: 75-200 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day

amoxicillin/clavulanate: 30 mg/kg/day orally given in 2 divided doses

Consider – antiviral therapy

Back

Consider –

antiviral therapy

Treatment recommended for SOME patients in selected patient group

In practice, many clinicians find that the increased risk of adverse effects (e.g., nausea and vomiting) in children outweighs the benefits. For more details, see Influenza infection.

Consider – switch to pathogen-directed antibiotic therapy

Back

Consider –

switch to pathogen-directed antibiotic therapy

Treatment recommended for SOME patients in selected patient group

If a causative pathogen is identified by microbiologic testing, switch the patient to an organism-specific antibiotic regimen, guided by sensitivity tests.[9]

Seek advice from your local microbiology team where needed.

≥3 months of age

Plus – empiric antibiotic therapy

Back

Plus –

empiric antibiotic therapy

Treatment recommended for ALL patients in selected patient group

The choice of empiric antibiotic regimen, route of administration, and duration of therapy will vary according to local guidelines and susceptibility patterns. Please refer to your local protocol.

In the US, parenteral therapy is recommended.[1][8] However, oral antibiotics may be recommended in some countries outside of the US; they are safe and effective for severe CAP, if tolerated.[9][52][53]

The US pediatric CAP guideline recommends empiric therapy with high-dose ampicillin or penicillin G first-line for any previously healthy, fully immunized child who is hospitalized 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.[1] Empiric therapy with a third-generation cephalosporin is recommended first-line if one or more of the following apply: the child is not fully immunized; or there is local evidence of significant penicillin resistance for invasive S pneumoniae; or the child has life-threatening infection. Levofloxacin is an alternative option in these patients. Patients on intravenous therapy may be switched to a suitable oral regimen when possible to complete the course.

In the UK, high-dose amoxicillin is recommended by the National Institute for Health and Care Excellence (NICE) and the British Thoracic Society (BTS) as the first-line antibiotic for most children.[9][17] If the child has high-severity CAP, NICE recommends amoxicillin/clavulanate first-line.[17] UK guidelines recommend to 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.[17]

If an atypical pathogen is suspected, empiric regimens differ from those recommended here. See Atypical pneumonia.

Systemic fluoroquinolone antibiotics 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; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[66] 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.

For more information on factors to consider when assessing whether a child is a nonresponder, see Management approach.

In the absence of any guidelines recommending optimal duration, empiric antibiotic treatment has traditionally been given for 7-10 days.[1][3] However, evidence now suggests that a shorter course is likely sufficient in many children.[10]

Primary options

ampicillin: 150-400 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day

penicillin G sodium: 100,000 to 250,000 units/kg/day intravenously given in divided doses every 4-6 hours

amoxicillin: children ≥3 months of age: 90 mg/kg/day orally given in 2 divided doses, maximum 4000 mg/day

Secondary options

ceftriaxone: 50-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 2 g/day

cefotaxime: 150 mg/kg/day intravenously given in divided doses every 8 hours, maximum 12 g/day

Tertiary options

levofloxacin: children ≥6 months of age: 16-20 mg/kg/day intravenously given in divided doses every 12 hours, maximum 750 mg/day; children ≥5 years of age: 8-10 mg/kg intravenously every 24 hours, maximum 750 mg/day

Consider – MRSA antibiotic cover

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Consider –

MRSA antibiotic cover

Treatment recommended for SOME patients in selected patient group

If methicillin-resistant Staphylococcus aureus (MRSA) is suspected, add empiric antibiotic cover according to local protocols. The US pediatric CAP guideline recommends clindamycin or vancomycin as options.[1]

Vancomycin is ototoxic and nephrotoxic and requires serum drug monitoring during treatment.

Primary options

clindamycin: 40 mg/kg/day intravenously given in divided doses every 6-8 hours

vancomycin: 40-60 mg/kg/day intravenously given in divided doses every 6-8 hours

Consider – antiviral therapy

Back

Consider –

antiviral therapy

Treatment recommended for SOME patients in selected patient group

Oseltamivir is recommended as the antiviral of choice by the AAP.[54] Depending on the child's age, other options may include inhaled zanamivir or oral baloxavir.[54]

However, there has been extensive debate over the use of antivirals, in particular whether or not oseltamivir does reduce complications in otherwise healthy children.[63][64] The World Health Organization guideline makes a conditional recommendation, based on low-quality evidence, for use of oseltamivir in individuals with severe influenza, but recommends against the use of other antivirals for this purpose.[6] In practice, many clinicians find that the increased risk of adverse effects (e.g., nausea and vomiting) in children outweighs any benefits. For more details, see Influenza infection.

Consider – switch to pathogen-directed antibiotic therapy

Back

Consider –

switch to pathogen-directed antibiotic therapy

Treatment recommended for SOME patients in selected patient group

If a causative pathogen is identified by microbiologic testing, switch the patient to an organism-specific antibiotic regimen, guided by sensitivity tests.[9]

Seek advice from your local microbiology team where needed.

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Community-acquired pneumonia in children

Treatment algorithm

outpatient (nonsevere)

supportive care

Primary options

empiric oral antibiotic therapy

Primary options

Secondary options

Tertiary options

antiviral therapy

inpatient management

inpatient (severe)

supportive care

Primary options

empiric antibiotic therapy

Primary options

antiviral therapy

switch to pathogen-directed antibiotic therapy

empiric antibiotic therapy

Primary options

antiviral therapy

switch to pathogen-directed antibiotic therapy

empiric antibiotic therapy

Primary options

Secondary options

Tertiary options

MRSA antibiotic cover

Primary options

antiviral therapy

switch to pathogen-directed antibiotic therapy